=====================================================
General NPI Number Information
=====================================================
NPI Number | 1174599146
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | BO S HUSBERG M.D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/28/2006
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 221 W COLORADO BLVD PAV II STE # 535
-----------------------------------------------------
City | DALLAS
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75208-2363
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 214-947-4400
-----------------------------------------------------
Fax | 214-947-4404
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3400 W WHEATLAND RD PAV III STE#260
-----------------------------------------------------
City | DALLAS
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75237-4418
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 214-947-7325
-----------------------------------------------------
Fax | 214-947-7349
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208600000X
-----------------------------------------------------
Taxonomy Name | Surgery Physician
-----------------------------------------------------
License Number | G8541
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------