=====================================================
General NPI Number Information
=====================================================
NPI Number | 1558666222
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | EXCLUSIVELY GYN
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/11/2011
-----------------------------------------------------
Last Update Date | 01/11/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 9659 N SAM HOUSTON PKWY E SUITE 150 #251
-----------------------------------------------------
City | HUMBLE
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77396-1529
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 281-226-0320
-----------------------------------------------------
Fax | 281-454-7691
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 9659 N SAM HOUSTON PKWY E SUITE 150 #251
-----------------------------------------------------
City | HUMBLE
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77396-1529
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 281-226-0320
-----------------------------------------------------
Fax | 281-454-7691
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OB/GYN
-----------------------------------------------------
Name | JEANNE SMITH
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 281-226-0320
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 174400000X
-----------------------------------------------------
Taxonomy Name | Specialist
-----------------------------------------------------
License Number | L7562
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------