=====================================================
General NPI Number Information
=====================================================
NPI Number | 1184241317
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | NDMD STAFFING, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/03/2020
-----------------------------------------------------
Last Update Date | 07/03/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 7460 WARREN PKWY STE 100
-----------------------------------------------------
City | FRISCO
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75034-4170
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 469-287-7825
-----------------------------------------------------
Fax | 800-514-1722
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 7460 WARREN PKWY STE 100
-----------------------------------------------------
City | FRISCO
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75034-4170
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 469-287-7825
-----------------------------------------------------
Fax | 800-514-1722
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MD
-----------------------------------------------------
Name | DR. SCOTT FAGAN
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 469-287-7825
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208D00000X
-----------------------------------------------------
Taxonomy Name | General Practice Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------