MEDICARE: KELLY EVANS JOSLIN MED., L.P.C.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YP2500X	Professional Counselor	10888	TX

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	2163LC	OTHER	TX	BC/BS PROVIDER NUMBER

General Provider Information

NPI Number	:	1033102603
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KELLY EVANS JOSLIN MED., L.P.C.

Provider Business Mailing Address
First Line	:	PO BOX 943
Second Line	:
City	:	ATLANTA
State	:	TX
Zip	:	75551-0943
Country	:	US
Telephone Number	:	903-796-0776
Fax Number	:	903-799-9776

Provider Business Practice Location Address
First Line	:	604 W MAIN ST
Second Line	:
City	:	ATLANTA
State	:	TX
Zip	:	75551-2529
Country	:	US
Telephone Number	:	903-796-0776
Fax Number	:	903-799-9776

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/29/2005
Last Update Date	:	07/09/2007

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