=====================================================
General NPI Number Information
=====================================================
NPI Number | 1215203625
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | TRINITY NORTH DALLAS NEUROLOGY, PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/29/2012
-----------------------------------------------------
Last Update Date | 07/10/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4325 N JOSEY LN PLAZA 3, SUITE 211
-----------------------------------------------------
City | CARROLLTON
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75010-4635
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 214-483-5665
-----------------------------------------------------
Fax | 214-483-5684
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4325 N JOSEY LN PLAZA 3, SUITE 211
-----------------------------------------------------
City | CARROLLTON
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75010-4635
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 214-483-5665
-----------------------------------------------------
Fax | 214-483-5684
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | NEUROLOGY/CLINICAL NEUROPHYSIOLOGY
-----------------------------------------------------
Name | DR. ELIZABETH SAMUEL
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 214-274-4706
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2084N0400X
-----------------------------------------------------
Taxonomy Name | Neurology Physician
-----------------------------------------------------
License Number | M0252
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------