=====================================================
General NPI Number Information
=====================================================
NPI Number | 1750632675
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | GREATER SOUTHWEST MEDICAL ASSOCIATES
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/02/2012
-----------------------------------------------------
Last Update Date | 10/02/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 815 IRA E WOODS AVE 200
-----------------------------------------------------
City | GRAPEVINE
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 76051-4008
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 817-488-0100
-----------------------------------------------------
Fax | 817-488-4568
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 815 IRA E WOODS AVE 200
-----------------------------------------------------
City | GRAPEVINE
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 76051-4008
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 817-488-0100
-----------------------------------------------------
Fax | 817-488-4568
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | ADMINISTRATOR
-----------------------------------------------------
Name | DR. IRBY HUNTER JR.
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 817-488-0100
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 314000000X
-----------------------------------------------------
Taxonomy Name | Skilled Nursing Facility
-----------------------------------------------------
License Number | F0809323
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------