=====================================================
General NPI Number Information
=====================================================
NPI Number | 1568405207
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | BRIDGET ANA WALSH DO
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/13/2006
-----------------------------------------------------
Last Update Date | 12/10/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1 CHOCTAW WAY
-----------------------------------------------------
City | TALIHINA
-----------------------------------------------------
State | OK
-----------------------------------------------------
Zip | 74571-2022
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 918-567-7000
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1120 FOXFIRE CIR
-----------------------------------------------------
City | ELBERTON
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30635-2616
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 706-248-1300
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207P00000X
-----------------------------------------------------
Taxonomy Name | Emergency Medicine Physician
-----------------------------------------------------
License Number | 034977
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207R00000X
-----------------------------------------------------
Taxonomy Name | Internal Medicine Physician
-----------------------------------------------------
License Number | 034977
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------