=====================================================
General NPI Number Information
=====================================================
NPI Number | 1538313002
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | FAMILY PRACTICE SPECIALISTS,PA
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/11/2008
-----------------------------------------------------
Last Update Date | 11/11/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 6300 W PARKER RD STE 225
-----------------------------------------------------
City | PLANO
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75093-8102
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 972-981-7827
-----------------------------------------------------
Fax | 972-981-7850
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 6300 W PARKER RD STE 225
-----------------------------------------------------
City | PLANO
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75093-8102
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 972-981-7827
-----------------------------------------------------
Fax | 972-981-7850
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | SUSAN PAYBERAH
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 972-981-7827
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 173000000X
-----------------------------------------------------
Taxonomy Name | Legal Medicine
-----------------------------------------------------
License Number | J9262
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------