=====================================================
General NPI Number Information
=====================================================
NPI Number | 1447602214
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | WAXAHACHIE MEDICAL PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/05/2016
-----------------------------------------------------
Last Update Date | 07/07/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 401 N HIGHWAY 77 SUITE # 1
-----------------------------------------------------
City | WAXAHACHIE
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75165-1130
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 214-619-5664
-----------------------------------------------------
Fax | 469-930-4446
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 401 N HIGHWAY 77 SUITE # 1
-----------------------------------------------------
City | WAXAHACHIE
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75165-1130
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 214-619-5664
-----------------------------------------------------
Fax | 469-930-4446
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MEDICAL DIRECTOR
-----------------------------------------------------
Name | BRENT W GALLOWAY
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 214-619-5664
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | N4420
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 261QM2500X
-----------------------------------------------------
Taxonomy Name | Medical Specialty Clinic/Center
-----------------------------------------------------
License Number | N4420
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------