=====================================================
General NPI Number Information
=====================================================
NPI Number | 1174929947
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PARKHILL MEDICAL, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/06/2014
-----------------------------------------------------
Last Update Date | 11/06/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1900 ENCHANTED WAY SUITE 100
-----------------------------------------------------
City | GRAPEVINE
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 76051-0965
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 817-421-1066
-----------------------------------------------------
Fax | 817-886-3657
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1900 ENCHANTED WAY SUITE 100
-----------------------------------------------------
City | GRAPEVINE
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 76051-0965
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 817-421-1066
-----------------------------------------------------
Fax | 817-886-3657
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MANAGING PARTNER/CEO
-----------------------------------------------------
Name | GLEN RAY WYANT
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 817-421-1066
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207LP3000X
-----------------------------------------------------
Taxonomy Name | Pediatric Anesthesiology Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207Y00000X
-----------------------------------------------------
Taxonomy Name | Otolaryngology Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 208000000X
-----------------------------------------------------
Taxonomy Name | Pediatrics Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #4
-----------------------------------------------------
Taxonomy Code | 207L00000X
-----------------------------------------------------
Taxonomy Name | Anesthesiology Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------