=====================================================
General NPI Number Information
=====================================================
NPI Number | 1003366485
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | TERRELL OB/GYN PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/10/2016
-----------------------------------------------------
Last Update Date | 10/10/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 109 TEJAS DR
-----------------------------------------------------
City | TERRELL
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75160-6676
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 903-454-2130
-----------------------------------------------------
Fax | 903-454-5487
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 8115
-----------------------------------------------------
City | GREENVILLE
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75404-8115
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 903-454-2130
-----------------------------------------------------
Fax | 903-454-5487
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | ACCOUNTS RECEIVABLE
-----------------------------------------------------
Name | MRS. DWON BLEVINS
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 903-454-2130
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207V00000X
-----------------------------------------------------
Taxonomy Name | Obstetrics & Gynecology Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------