NPIMap

Organization Active NPI

Fort Worth Lung Clinic, PA

  • Primary Care Clinic/Center
  • Burleson, TX
National Provider Identifier
1558655274
Registry record updated Feb 19, 2025
On this page

Key facts

NPPES NPI Registry
Primary specialty
Primary Care Clinic/CenterTaxonomy code 261QP2300X
License
N0617 Issued in TX
Legal business name
FORT WORTH LUNG CLINIC, PA
Practice address
11803 South Fwy Ste 136
Burleson, TX 76028-8460
Phone
(817) 568-8411
Fax
(817) 568-8414
NPI assigned
May 31, 2011
Last updated
Feb 19, 2025By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Feb 19, 2025

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Dereje Sahel Ayo, MDNPI 1295705325
Title
President
Phone
(817) 739-1080

Authorized official NPPES reports the official by name only. The link goes to the one practitioner connected to this organization with that name.

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Primary Care Clinic/Center 261QP2300X N0617 TX Primary

Addresses

Primary practice location

11803 South Fwy Ste 136
Burleson, TX 76028-8460

Mailing address

PO Box 16284
Fort Worth, TX 76162-0284
Phone (817) 739-1080

Other practice location 1

800 8th Ave Ste 412
Fort Worth, TX 76104-2618
Phone (817) 336-8773

Other identifiers 1

IdentifierTypeStateIssuer
N0617OtherTXLICENCE

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in TX

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20110923000606 TX Part B Supplier - Clinic/Group Practice 6204007123 Receives reassigned benefits from 10 practitioners
Practice locations: Burleson, TX; Fort Worth, TX

National Provider Directory

National Provider Directory

Locations

11803 South Fwy
Ste 128
Burleson, TX 76028

740 S Crowley Rd
Ste 7
Crowley, TX 76036

800 8th Ave
Ste 142
Fort Worth, TX 76104
Phone (817) 336-8773

800 8th Ave
Ste 412
Ft Worth, TX 76104
Phone (817) 336-0337

Interoperability endpoints

  • FHIR API: https://fhir4.healow.com/fhir/r4/AHFFCD

Practitioners & affiliated clinicians

Practitioners 10

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1306800000000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1739923200000",
    "number": "1558655274",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "PO BOX 16284",
            "city": "FORT WORTH",
            "state": "TX",
            "postal_code": "761620284",
            "telephone_number": "817-739-1080",
            "fax_number": "817-370-7942"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "11803 SOUTH FWY STE 136",
            "city": "BURLESON",
            "state": "TX",
            "postal_code": "760288460",
            "telephone_number": "817-568-8411",
            "fax_number": "817-568-8414"
        }
    ],
    "practiceLocations": [
        {
            "address_1": "800 8th Ave Ste 412",
            "address_purpose": "LOCATION",
            "city": "Fort Worth",
            "state": "TX",
            "postal_code": "761042618",
            "country_code": "US",
            "telephone_number": "817-336-8773",
            "fax_number": "817-338-1063",
            "country_name": "United States",
            "address_type": "DOM"
        }
    ],
    "basic": {
        "organization_name": "FORT WORTH LUNG CLINIC, PA",
        "organizational_subpart": "NO",
        "enumeration_date": "2011-05-31",
        "last_updated": "2025-02-19",
        "certification_date": "2025-02-19",
        "status": "A",
        "authorized_official_last_name": "AYO",
        "authorized_official_first_name": "DEREJE",
        "authorized_official_middle_name": "SAHEL",
        "authorized_official_title_or_position": "PRESIDENT",
        "authorized_official_telephone_number": "817-739-1080",
        "authorized_official_credential": "MD"
    },
    "taxonomies": [
        {
            "code": "261QP2300X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Primary Care",
            "state": "TX",
            "license": "N0617",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "LICENCE",
            "identifier": "N0617",
            "state": "TX"
        }
    ],
    "endpoints": [],
    "other_names": []
}

Other providers in Burleson, TX

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Feb 19, 2025; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.