=====================================================
General NPI Number Information
=====================================================
NPI Number | 1376698944
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PHYSIATRY SERVICE ORGANIZATION, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/24/2007
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 103 N 1ST ST
-----------------------------------------------------
City | ROCKWALL
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75087-3033
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 214-403-3959
-----------------------------------------------------
Fax | 817-284-3505
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 678413
-----------------------------------------------------
City | DALLAS
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75267-8413
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 214-403-3959
-----------------------------------------------------
Fax | 817-284-3505
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | SECRETARY
-----------------------------------------------------
Name | GWEN A. FIELDS
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 214-403-3959
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208100000X
-----------------------------------------------------
Taxonomy Name | Physical Medicine & Rehabilitation Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------