=====================================================
General NPI Number Information
=====================================================
NPI Number | 1831811918
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SUNDANCE PHYSICAL MEDICINE PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/14/2022
-----------------------------------------------------
Last Update Date | 10/19/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1400 W 7TH ST STE 450
-----------------------------------------------------
City | FORT WORTH
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 76102-2601
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 817-935-8200
-----------------------------------------------------
Fax | 817-887-2052
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3829 CATHEDRAL LAKE DR
-----------------------------------------------------
City | FRISCO
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75034-3871
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 337-255-7011
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CREDENTIALING DIRECTOR
-----------------------------------------------------
Name | MS. GENNIE BUDET
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 702-462-9729
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207P00000X
-----------------------------------------------------
Taxonomy Name | Emergency Medicine Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 363LF0000X
-----------------------------------------------------
Taxonomy Name | Family Nurse Practitioner
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 207R00000X
-----------------------------------------------------
Taxonomy Name | Internal Medicine Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------