=====================================================
General NPI Number Information
=====================================================
NPI Number | 1174933014
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | WEATHERFORD EMERGENCY PHYSICIANS GROUP PA
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/30/2014
-----------------------------------------------------
Last Update Date | 04/30/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 713 E ANDERSON ST
-----------------------------------------------------
City | WEATHERFORD
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 76086-5705
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 817-451-4208
-----------------------------------------------------
Fax | 817-563-3699
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 6300 RIDGLEA PL SUITE 201
-----------------------------------------------------
City | FORT WORTH
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 76116-5704
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 817-451-4208
-----------------------------------------------------
Fax | 817-563-3699
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/PRESIDENT
-----------------------------------------------------
Name | DR. NADEEM KHAN
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 817-451-4208
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207P00000X
-----------------------------------------------------
Taxonomy Name | Emergency Medicine Physician
-----------------------------------------------------
License Number | K8777
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------