=====================================================
General NPI Number Information
=====================================================
NPI Number | 1669613105
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | KINGSBROOK JEWISH MEDICAL CENTER
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/12/2009
-----------------------------------------------------
Last Update Date | 03/12/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1404 SAVOY CT
-----------------------------------------------------
City | COLLEYVILLE
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 76034-6267
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 682-365-3371
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1404 SAVOY CT
-----------------------------------------------------
City | COLLEYVILLE
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 76034-6267
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 682-365-3371
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | RESIDENT
-----------------------------------------------------
Name | DR. YUE-QING TAN
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 682-365-3371
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 282NC0060X
-----------------------------------------------------
Taxonomy Name | Critical Access Hospital
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------