=====================================================
General NPI Number Information
=====================================================
NPI Number | 1437147550
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JERRY WAYNE SCHWARZBACH MD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/12/2005
-----------------------------------------------------
Last Update Date | 10/27/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3414 GOLDEN RD
-----------------------------------------------------
City | TYLER
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75701-8336
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 903-939-7500
-----------------------------------------------------
Fax | 903-939-7728
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3414 GOLDEN RD
-----------------------------------------------------
City | TYLER
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75701-8336
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 903-939-5000
-----------------------------------------------------
Fax | 903-939-7728
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208100000X
-----------------------------------------------------
Taxonomy Name | Physical Medicine & Rehabilitation Physician
-----------------------------------------------------
License Number | H4684
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------