=====================================================
General NPI Number Information
=====================================================
NPI Number | 1104022706
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | RAPHEM MEDICAL PRACTICE PA
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/21/2007
-----------------------------------------------------
Last Update Date | 07/01/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 614 MATLOCK CENTRE CIR
-----------------------------------------------------
City | ARLINGTON
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 76015-2536
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 817-548-9092
-----------------------------------------------------
Fax | 817-548-9094
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 614 MATLOCK CENTRE CIR
-----------------------------------------------------
City | ARLINGTON
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 76015-2536
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 817-548-9092
-----------------------------------------------------
Fax | 817-548-9094
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | JOSEPH M MEGWA
-----------------------------------------------------
Credential | M.D
-----------------------------------------------------
Telephone | 817-548-9092
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | M0176
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------