=====================================================
General NPI Number Information
=====================================================
NPI Number | 1770638090
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | PETER PATRICK SFORZA M.D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/25/2007
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1360 ANTIOCH RD
-----------------------------------------------------
City | CAVE CITY
-----------------------------------------------------
State | AR
-----------------------------------------------------
Zip | 72521-9411
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 870-793-6940
-----------------------------------------------------
Fax | 870-793-6940
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1360 ANTIOCH RD
-----------------------------------------------------
City | CAVE CITY
-----------------------------------------------------
State | AR
-----------------------------------------------------
Zip | 72521-9411
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 870-793-6940
-----------------------------------------------------
Fax | 870-793-6940
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2085R0202X
-----------------------------------------------------
Taxonomy Name | Diagnostic Radiology Physician
-----------------------------------------------------
License Number | 0101040333
-----------------------------------------------------
License Number State | VA
-----------------------------------------------------