Provider Demographics
NPI:1609172527
Name:SHORT FAMILY MEDICAL CENTER PA
Entity type:Organization
Organization Name:SHORT FAMILY MEDICAL CENTER PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:JACKY
Authorized Official - Middle Name:PAUL
Authorized Official - Last Name:SHORT
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:817-295-5200
Mailing Address - Street 1:101 NW ELLISON ST
Mailing Address - Street 2:
Mailing Address - City:BURLESON
Mailing Address - State:TX
Mailing Address - Zip Code:76028-4745
Mailing Address - Country:US
Mailing Address - Phone:817-295-5200
Mailing Address - Fax:817-295-5210
Practice Address - Street 1:101 NW ELLISON ST
Practice Address - Street 2:
Practice Address - City:BURLESON
Practice Address - State:TX
Practice Address - Zip Code:76028-4745
Practice Address - Country:US
Practice Address - Phone:817-295-5200
Practice Address - Fax:817-295-5210
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-02-10
Last Update Date:2011-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXK5401261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care