=====================================================
General NPI Number Information
=====================================================
NPI Number | 1154628998
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BAYLOR FAMILY MEDICINE AT GARLAND
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/14/2011
-----------------------------------------------------
Last Update Date | 02/14/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 601 CLARA BARTON STE 340
-----------------------------------------------------
City | GARLAND
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75042
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 972-272-6554
-----------------------------------------------------
Fax | 972-272-7929
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 601 CLARA BARTON BLVD STE 340
-----------------------------------------------------
City | GARLAND
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75042-5755
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 972-272-6552
-----------------------------------------------------
Fax | 972-272-7929
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DIRECTOR
-----------------------------------------------------
Name | DR. LESLIE TINGLE
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 972-272-6554
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251B00000X
-----------------------------------------------------
Taxonomy Name | Case Management Agency
-----------------------------------------------------
License Number | 33763
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------