=====================================================
General NPI Number Information
=====================================================
NPI Number | 1023297371
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | JOHNNY QUBTY, MD,PA
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/02/2007
-----------------------------------------------------
Last Update Date | 11/02/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3601 21ST ST SUITE 3-A
-----------------------------------------------------
City | LUBBOCK
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 79410-1229
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 806-771-7877
-----------------------------------------------------
Fax | 806-771-7474
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3601 21ST ST SUITE 3-A
-----------------------------------------------------
City | LUBBOCK
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 79410-1229
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 806-771-5205
-----------------------------------------------------
Fax | 806-771-7474
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | BILLING ADMINISTRATOR
-----------------------------------------------------
Name | VICKEY R. COOPER
-----------------------------------------------------
Credential | CPC
-----------------------------------------------------
Telephone | 806-771-5205
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208VP0014X
-----------------------------------------------------
Taxonomy Name | Interventional Pain Medicine Physician
-----------------------------------------------------
License Number | H2703
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------