=====================================================
General NPI Number Information
=====================================================
NPI Number | 1821346529
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | JEMEZ MOUNTAIN EMERGENCY PHYSICIANS LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/28/2012
-----------------------------------------------------
Last Update Date | 03/04/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3917 WEST RD
-----------------------------------------------------
City | LOS ALAMOS
-----------------------------------------------------
State | NM
-----------------------------------------------------
Zip | 87544-2275
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 800-355-0808
-----------------------------------------------------
Fax | 610-834-2862
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 13737 NOEL RD STE 1600
-----------------------------------------------------
City | DALLAS
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75240-1331
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 469-401-2386
-----------------------------------------------------
Fax | 214-712-2444
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | JOSEPH W. TAYLOR
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 469-401-2383
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207P00000X
-----------------------------------------------------
Taxonomy Name | Emergency Medicine Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------