=====================================================
General NPI Number Information
=====================================================
NPI Number | 1851696058
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KEVIN R MYERS MD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/19/2011
-----------------------------------------------------
Last Update Date | 05/11/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4780 N JOSEY LN
-----------------------------------------------------
City | CARROLLTON
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75010-4615
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 972-492-1334
-----------------------------------------------------
Fax | 972-492-5174
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4780 N JOSEY LN
-----------------------------------------------------
City | CARROLLTON
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75010-4615
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 972-492-1334
-----------------------------------------------------
Fax | 972-492-5174
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208600000X
-----------------------------------------------------
Taxonomy Name | Surgery Physician
-----------------------------------------------------
License Number | MD.34159
-----------------------------------------------------
License Number State | AL
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207X00000X
-----------------------------------------------------
Taxonomy Name | Orthopaedic Surgery Physician
-----------------------------------------------------
License Number | Q5505
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------