=====================================================
General NPI Number Information
=====================================================
NPI Number | 1982866257
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BLUEBONNET SURGICAL ASSOCIATES, P,A,
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/27/2008
-----------------------------------------------------
Last Update Date | 05/11/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3430 W WHEATLAND RD SUITE 407
-----------------------------------------------------
City | DALLAS
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75237-3446
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 972-283-9900
-----------------------------------------------------
Fax | 972-283-9905
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3430 W WHEATLAND RD SUITE 407
-----------------------------------------------------
City | DALLAS
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75237-3446
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 972-283-9900
-----------------------------------------------------
Fax | 972-283-9905
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. LAUREL L HUMPHREY POWELL
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 972-283-9900
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208600000X
-----------------------------------------------------
Taxonomy Name | Surgery Physician
-----------------------------------------------------
License Number | M1773
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------