MEDICARE: PREMIER GASTROENTEROLOGY OF TEXAS PA

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	207RG0100X	Gastroenterology Physician	L0393	TX

General Provider Information

NPI Number	:	1265719140
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PREMIER GASTROENTEROLOGY OF TEXAS PA

Provider Business Mailing Address
First Line	:	7777 FOREST LANE BLDG. C
Second Line	:	SUITE 204
City	:	DALLAS
State	:	TX
Zip	:	75230-2513
Country	:	US
Telephone Number	:	972-566-5266
Fax Number	:	972-566-5245

Provider Business Practice Location Address
First Line	:	7777 FOREST LANE BLDG. C
Second Line	:	SUITE 204
City	:	DALLAS
State	:	TX
Zip	:	75230-2513
Country	:	US
Telephone Number	:	972-566-5266
Fax Number	:	972-566-5245

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. DAMIEN BASSAM MALLAT
Credential	:	M.D.
Telephone Number	:	972-566-5266

Provider Enumeration Date	:	11/07/2011
Last Update Date	:	04/02/2012

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