=====================================================
General NPI Number Information
=====================================================
NPI Number | 1275710071
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | GUTHRIE MEDICAL CLINIC INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/24/2008
-----------------------------------------------------
Last Update Date | 01/24/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2706 AILEEN BLVD STE B
-----------------------------------------------------
City | GREENVILLE
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75402-6486
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 903-454-2453
-----------------------------------------------------
Fax | 903-454-4531
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2706 AILEEN BLVD STE B
-----------------------------------------------------
City | GREENVILLE
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75402-6486
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 903-454-2453
-----------------------------------------------------
Fax | 903-454-4531
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PA
-----------------------------------------------------
Name | MS. LAURE L GUTHRIE
-----------------------------------------------------
Credential | PA
-----------------------------------------------------
Telephone | 903-454-2453
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363A00000X
-----------------------------------------------------
Taxonomy Name | Physician Assistant
-----------------------------------------------------
License Number | PA01187
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------