| Southside Medical Clinic | |
|
546 W Seminary Dr Ste A Fort Worth TX 76115-1361 | |
| (817) 924-7978 | |
| Not Available |
| Full Name | Southside Medical Clinic |
|---|---|
| Speciality | Family Medicine |
| Location | 546 W Seminary Dr Ste A, Fort Worth, Texas |
| Authorized Official Name and Position | Pamela E Thomson (CREDENTIALING MANAGER) |
| Authorized Official Contact | 8177447524 |
| Accepts Medicare Insurance | Yes. This clinic participates in medicare program and accept medicare insurance. |
| Mailing Address | Practice Location Address |
|---|---|
| Southside Medical Clinic 546 W Seminary Dr Ste A Fort Worth TX 76115-1361 Ph: (817) 924-7978 | Southside Medical Clinic 546 W Seminary Dr Ste A Fort Worth TX 76115-1361 Ph: (817) 924-7978 |
| NPI Number | 1043331812 |
|---|---|
| Provider Enumeration Date | 04/02/2007 |
| Last Update Date | 09/18/2023 |
| Medicare PECOS PAC ID | 7911981600 |
|---|---|
| Medicare Enrollment ID | O20040618000245 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1043331812 | NPI | - | NPPES |
| 4172611-01 | Medicaid | TX | |
| 4172611-02 | Medicaid | TX |
| Taxonomy | Type | License (State) | Status |
|---|---|---|---|
| 207Q00000X | Family Medicine | (* (Not Available)) | Primary |
| 363A00000X | Physician Assistant | (* (Not Available)) | Secondary |
| Provider Name | Robert L Campbell |
|---|---|
| Provider Type | Practitioner - Family Practice |
| Provider Identifiers | NPI Number: 1992929947 PECOS PAC ID: 2466345848 Enrollment ID: I20040209000148 |
| Provider Name | Mellissa May Bruce |
|---|---|
| Provider Type | Practitioner - Nurse Practitioner |
| Provider Identifiers | NPI Number: 1841884608 PECOS PAC ID: 1456767789 Enrollment ID: I20210310002058 |
| Provider Name | Benson Plavilapadinjattethil |
|---|---|
| Provider Type | Practitioner - Nurse Practitioner |
| Provider Identifiers | NPI Number: 1205452919 PECOS PAC ID: 5092110015 Enrollment ID: I20210828000184 |
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