Provider Demographics
NPI:1437334042
Name:ABBOTT CLINIC, PA
Entity type:Organization
Organization Name:ABBOTT CLINIC, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:PHILIP
Authorized Official - Middle Name:DON
Authorized Official - Last Name:ABBOTT
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:817-590-2395
Mailing Address - Street 1:3700 RUFE SNOW DR
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76180-8848
Mailing Address - Country:US
Mailing Address - Phone:817-590-2395
Mailing Address - Fax:817-595-1445
Practice Address - Street 1:3700 RUFE SNOW DR
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76180-8848
Practice Address - Country:US
Practice Address - Phone:817-590-2395
Practice Address - Fax:817-595-1445
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-02
Last Update Date:2013-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXC8872207VG0400X, 207VF0040X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207VF0040XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyUrogynecology and Reconstructive Pelvic SurgeryGroup - Multi-Specialty
No207VG0400XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXC12562Medicare UPIN
TX0A5549Medicare PIN