=====================================================
General NPI Number Information
=====================================================
NPI Number | 1033433420
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PRO PHYSICIANS CLINIC PA
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/15/2010
-----------------------------------------------------
Last Update Date | 03/15/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 7501 LAKEVIEW PKWY
-----------------------------------------------------
City | ROWLETT
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75088-9322
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 972-475-4999
-----------------------------------------------------
Fax | 972-475-4422
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 678234
-----------------------------------------------------
City | DALLAS
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75267-8234
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 972-475-4999
-----------------------------------------------------
Fax | 972-475-4422
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO
-----------------------------------------------------
Name | JON D. TRYGGESTAD
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 972-573-4611
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2085R0001X
-----------------------------------------------------
Taxonomy Name | Radiation Oncology Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------