=====================================================
General NPI Number Information
=====================================================
NPI Number | 1760652978
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SMG SIGNATURE MEDICAL GROUP
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/04/2008
-----------------------------------------------------
Last Update Date | 03/05/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2022 REGIONAL MEDICAL DRIVE SUITE 1319
-----------------------------------------------------
City | WHARTON
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77488
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 979-531-8801
-----------------------------------------------------
Fax | 979-531-8802
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2022 REGIONAL MEDICAL DRIVE SUITE 1319
-----------------------------------------------------
City | WHARTON
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77488
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 979-531-8801
-----------------------------------------------------
Fax | 979-531-8802
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CHIEF FINANCIAL OFFICER
-----------------------------------------------------
Name | MR. ROBERT M STERLING
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 832-758-1258
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208600000X
-----------------------------------------------------
Taxonomy Name | Surgery Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------