=====================================================
General NPI Number Information
=====================================================
NPI Number | 1649687278
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BLUE STEM MHT LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/15/2014
-----------------------------------------------------
Last Update Date | 01/02/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3460 E FRANK PHILLIPS BLVD
-----------------------------------------------------
City | BARTLESVILLE
-----------------------------------------------------
State | OK
-----------------------------------------------------
Zip | 74006-2406
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 918-214-2162
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1515 HERITAGE DRIVE SUITE 110
-----------------------------------------------------
City | MCKINNEY
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75069-3379
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 855-860-2109
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | ANDERSON MEHRLE
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 918-332-3665
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207R00000X
-----------------------------------------------------
Taxonomy Name | Internal Medicine Physician
-----------------------------------------------------
License Number | 26605
-----------------------------------------------------
License Number State | OK
-----------------------------------------------------