=====================================================
General NPI Number Information
=====================================================
NPI Number | 1740419340
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SEQUOYAH CARE PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/06/2009
-----------------------------------------------------
Last Update Date | 08/22/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 828 KIRKWOOD DR
-----------------------------------------------------
City | DALLAS
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75218-2208
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 972-216-9511
-----------------------------------------------------
Fax | 972-216-9580
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 851438
-----------------------------------------------------
City | MESQUITE
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75185-1438
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 972-216-9511
-----------------------------------------------------
Fax | 972-216-9580
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | ADOLPHUS V GIST
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 972-216-9511
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207R00000X
-----------------------------------------------------
Taxonomy Name | Internal Medicine Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------