=====================================================
General NPI Number Information
=====================================================
NPI Number | 1174771554
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | TEXAS PALLIATIVE CARE
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/28/2008
-----------------------------------------------------
Last Update Date | 08/28/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4111 UNIVERSITY BLVD
-----------------------------------------------------
City | TYLER
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75701-6623
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 903-266-3400
-----------------------------------------------------
Fax | 903-566-0291
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4111 UNIVERSITY BLVD
-----------------------------------------------------
City | TYLER
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75701-6623
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 903-266-3400
-----------------------------------------------------
Fax | 903-566-0291
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT/CEO
-----------------------------------------------------
Name | MARJORIE REAM
-----------------------------------------------------
Credential | RN, MN
-----------------------------------------------------
Telephone | 903-266-3400
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207RH0002X
-----------------------------------------------------
Taxonomy Name | Hospice and Palliative Medicine (Internal Medicine) Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 2080H0002X
-----------------------------------------------------
Taxonomy Name | Pediatric Hospice and Palliative Medicine Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 207QH0002X
-----------------------------------------------------
Taxonomy Name | Hospice and Palliative Medicine (Family Medicine) Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------