=====================================================
General NPI Number Information
=====================================================
NPI Number | 1093994865
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ELIZABETH EVERSULL MD
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/30/2007
-----------------------------------------------------
Last Update Date | 11/27/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1600 COIT RD SUITE 103
-----------------------------------------------------
City | PLANO
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75075-6174
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 214-516-9722
-----------------------------------------------------
Fax | 972-612-5048
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 835926
-----------------------------------------------------
City | RICHARDSON
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75083-5926
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 214-516-9722
-----------------------------------------------------
Fax | 972-612-5048
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PROPRIETOR
-----------------------------------------------------
Name | DR. ELIZABETH INDIA EVERSULL
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 214-516-9722
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QP3300X
-----------------------------------------------------
Taxonomy Name | Pain Clinic/Center
-----------------------------------------------------
License Number | L5328
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------