=====================================================
General NPI Number Information
=====================================================
NPI Number | 1043529944
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | REGIONAL PHYSICIAN SERVICES OF TEXAS, P.A.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/27/2010
-----------------------------------------------------
Last Update Date | 11/10/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 20103 FALCON CHASE CT
-----------------------------------------------------
City | SPRING
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77379-2953
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 480-862-1677
-----------------------------------------------------
Fax | 480-718-7643
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 9201 EAST MOUNTAIN VIEW RD SUITE 220
-----------------------------------------------------
City | SCOTTSDALE
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85258-5172
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 480-862-1700
-----------------------------------------------------
Fax | 480-907-1537
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | SUPERVISOR, PROVIDER ENROLLMENT
-----------------------------------------------------
Name | STEPHANIE PETERSON
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 480-862-1677
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363L00000X
-----------------------------------------------------
Taxonomy Name | Nurse Practitioner
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------