=====================================================
General NPI Number Information
=====================================================
NPI Number | 1760995575
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | GRAYSON DIGESTIVE HEALTH PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/15/2017
-----------------------------------------------------
Last Update Date | 08/05/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 204 MEDICAL DR STE 240
-----------------------------------------------------
City | SHERMAN
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75092-6366
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 903-364-4525
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 837
-----------------------------------------------------
City | HOWE
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75459-0837
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 903-487-2248
-----------------------------------------------------
Fax | 903-487-2306
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | JOSEPH KIM
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 903-364-4525
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207RG0100X
-----------------------------------------------------
Taxonomy Name | Gastroenterology Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------