=====================================================
General NPI Number Information
=====================================================
NPI Number | 1790725083
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MERYLE DOROTHY SMITH CRNA
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/07/2006
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 803 W LAMPASAS ST
-----------------------------------------------------
City | ENNIS
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75119-4535
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 972-875-0900
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 140430
-----------------------------------------------------
City | DALLAS
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75214-0430
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 214-522-0210
-----------------------------------------------------
Fax | 214-522-0474
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207L00000X
-----------------------------------------------------
Taxonomy Name | Anesthesiology Physician
-----------------------------------------------------
License Number | 514500
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------