=====================================================
General NPI Number Information
=====================================================
NPI Number | 1609141829
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BAY AREA ADVANCED OBGYN, PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/21/2012
-----------------------------------------------------
Last Update Date | 03/05/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 450 W MEDICAL CENTER BLVD STE 410
-----------------------------------------------------
City | WEBSTER
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77598-4233
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 832-331-1125
-----------------------------------------------------
Fax | 281-724-1077
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 450 W MEDICAL CENTER BLVD STE 410
-----------------------------------------------------
City | WEBSTER
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77598-4233
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 832-331-1125
-----------------------------------------------------
Fax | 281-724-1077
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MD
-----------------------------------------------------
Name | ERWIN MANFRED KORMAN
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 832-331-1125
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207V00000X
-----------------------------------------------------
Taxonomy Name | Obstetrics & Gynecology Physician
-----------------------------------------------------
License Number | F4912
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------