=====================================================
General NPI Number Information
=====================================================
NPI Number | 1922410935
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MORRIS MEDICAL GROUP PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/24/2014
-----------------------------------------------------
Last Update Date | 05/24/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1941 BISHOP LN #508
-----------------------------------------------------
City | LOUISVILLE
-----------------------------------------------------
State | KY
-----------------------------------------------------
Zip | 40218-1922
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 817-739-7641
-----------------------------------------------------
Fax | 817-288-0758
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 96164
-----------------------------------------------------
City | SOUTHLAKE
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 76092-0126
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 817-739-7641
-----------------------------------------------------
Fax | 817-288-0758
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MANAGING MEMBER
-----------------------------------------------------
Name | DR. JERRY W MORRIS
-----------------------------------------------------
Credential | DO
-----------------------------------------------------
Telephone | 817-739-7641
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208D00000X
-----------------------------------------------------
Taxonomy Name | General Practice Physician
-----------------------------------------------------
License Number | 03530
-----------------------------------------------------
License Number State | KY
-----------------------------------------------------