=====================================================
General NPI Number Information
=====================================================
NPI Number | 1396073672
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | RONALD PHILLEAUX M.D. P.A.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/25/2009
-----------------------------------------------------
Last Update Date | 11/25/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 10246 MIDWAY RD SUITE 105
-----------------------------------------------------
City | DALLAS
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75229-6233
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 214-357-9481
-----------------------------------------------------
Fax | 214-902-0636
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 10246 MIDWAY RD. SUITE 105
-----------------------------------------------------
City | DALLAS
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75229-6223
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 214-357-9481
-----------------------------------------------------
Fax | 214-902-0636
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MEDICAL DOCTOR/OWNER
-----------------------------------------------------
Name | DR. RONALDL WREYBURN PHILLEAUX
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 214-357-9481
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 305R00000X
-----------------------------------------------------
Taxonomy Name | Preferred Provider Organization
-----------------------------------------------------
License Number | D-1883
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 305R00000X
-----------------------------------------------------
Taxonomy Name | Preferred Provider Organization
-----------------------------------------------------
License Number | D1883
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------