=====================================================
General NPI Number Information
=====================================================
NPI Number | 1538885348
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | JABER MEDICINE PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/13/2022
-----------------------------------------------------
Last Update Date | 10/13/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3504 NE 24TH AVE
-----------------------------------------------------
City | AMARILLO
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 79107-6920
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 806-381-1732
-----------------------------------------------------
Fax | 806-381-0748
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 5159
-----------------------------------------------------
City | AMARILLO
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 79117-5159
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 806-381-1732
-----------------------------------------------------
Fax | 806-381-0748
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | SOLE MEMBER/PRESIDENT
-----------------------------------------------------
Name | MOUIN JABER
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 806-381-1732
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207R00000X
-----------------------------------------------------
Taxonomy Name | Internal Medicine Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------