=====================================================
General NPI Number Information
=====================================================
NPI Number | 1720045818
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | TEXAS EM-I MEDICAL SERVICES, P.A.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/01/2006
-----------------------------------------------------
Last Update Date | 02/28/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3500 GASTON AVE
-----------------------------------------------------
City | DALLAS
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75246-2096
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 214-820-2501
-----------------------------------------------------
Fax | 214-820-4618
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 41633
-----------------------------------------------------
City | PHILADELPHIA
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 19101-1633
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 800-355-0808
-----------------------------------------------------
Fax | 214-712-2444
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT/OWNER
-----------------------------------------------------
Name | DR. WILLIAM C. JERNBERG
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 214-712-2000
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207P00000X
-----------------------------------------------------
Taxonomy Name | Emergency Medicine Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------