MEDICARE: SMG SIGNATURE MEDICAL GROUP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QR1300X	Rural Health Clinic/Center

General Provider Information

NPI Number	:	1114295193
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SMG SIGNATURE MEDICAL GROUP

Provider Business Mailing Address
First Line	:	PO BOX 841648
Second Line	:
City	:	DALLAS
State	:	TX
Zip	:	75284-1648
Country	:	US
Telephone Number	:	979-282-6800
Fax Number	:	979-282-6805

Provider Business Practice Location Address
First Line	:	720 AVENUE F N
Second Line	:
City	:	BAY CITY
State	:	TX
Zip	:	77414-9573
Country	:	US
Telephone Number	:	979-282-6800
Fax Number	:	979-282-6805

Authorized Official
Title or Position	:	CEO
Name	:	RANDY SLACK
Credential	:
Telephone Number	:	979-282-1600

Provider Enumeration Date	:	12/06/2011
Last Update Date	:	12/06/2011

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