=====================================================
General NPI Number Information
=====================================================
NPI Number | 1639351505
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PRACTICAL PEDIATRICS
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/03/2007
-----------------------------------------------------
Last Update Date | 12/03/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 811 IRA E WOODS AVE.
-----------------------------------------------------
City | GRAPEVINE
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 76051-4012
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 817-481-3585
-----------------------------------------------------
Fax | 817-421-6529
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 811 IRA E WOODS AVE
-----------------------------------------------------
City | GRAPEVINE
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 76051-8722
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 817-481-3585
-----------------------------------------------------
Fax | 817-421-6529
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER PEDIATRICAN
-----------------------------------------------------
Name | DR. MICHAEL W MCCOY
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 817-481-3585
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 174400000X
-----------------------------------------------------
Taxonomy Name | Specialist
-----------------------------------------------------
License Number | H5589
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------