=====================================================
General NPI Number Information
=====================================================
NPI Number | 1215068309
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PEDIATRIC ASSOCIATES OF WYLIE, P.A.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/08/2007
-----------------------------------------------------
Last Update Date | 02/28/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 501 WOODBRIDGE PARKWAY
-----------------------------------------------------
City | WYLIE
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75098
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 972-442-2300
-----------------------------------------------------
Fax | 972-442-2180
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 125
-----------------------------------------------------
City | WYLIE
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75098-0125
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 972-442-2300
-----------------------------------------------------
Fax | 972-442-2180
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | BILLING MANAGER
-----------------------------------------------------
Name | MRS. RUTH A. STROTHER
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 972-442-2300
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208000000X
-----------------------------------------------------
Taxonomy Name | Pediatrics Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------