=====================================================
General NPI Number Information
=====================================================
NPI Number | 1336333806
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | INWOOD VILLAGE PEDIATRICS
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/28/2007
-----------------------------------------------------
Last Update Date | 06/20/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5470 W. LOVERS LANE SUITE 330
-----------------------------------------------------
City | DALLAS
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75209
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 214-956-7337
-----------------------------------------------------
Fax | 214-466-8289
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5470 W. LOVERS LANE SUITE 330
-----------------------------------------------------
City | DALLAS
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75209
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 214-956-7337
-----------------------------------------------------
Fax | 214-466-8289
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PARTNER/OWNER
-----------------------------------------------------
Name | DR. TAMMY L KENNEDY
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 214-956-7337
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208000000X
-----------------------------------------------------
Taxonomy Name | Pediatrics Physician
-----------------------------------------------------
License Number | L4488
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 261QM2500X
-----------------------------------------------------
Taxonomy Name | Medical Specialty Clinic/Center
-----------------------------------------------------
License Number | L4488
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------