MEDICARE: MEDDIVE LLC

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	207PE0005X	Undersea and Hyperbaric Medicine (Emergency Medicine) Physician

General Provider Information

NPI Number	:	1659854024
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MEDDIVE LLC

Provider Business Mailing Address
First Line	:	900 PARKER SQ STE 250
Second Line	:
City	:	FLOWER MOUND
State	:	TX
Zip	:	75028-7440
Country	:	US
Telephone Number	:	972-795-0563
Fax Number	:	972-483-2194

Provider Business Practice Location Address
First Line	:	4351 BOOTH CALLOWAY RD STE 410
Second Line	:
City	:	NORTH RICHLAND HILLS
State	:	TX
Zip	:	76180-7381
Country	:	US
Telephone Number	:	817-255-1170
Fax Number	:	817-255-1171

Authorized Official
Title or Position	:	SR. VICE PRESIDENT
Name	:	MR. DAVID JOHNSTON
Credential	:
Telephone Number	:	972-795-0563

Provider Enumeration Date	:	09/12/2018
Last Update Date	:	09/12/2018

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