MEDICARE: SOUTHLAKE HOSPITALISTS LLC

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	207R00000X	Internal Medicine Physician	M1046	TX

General Provider Information

NPI Number	:	1033564729
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SOUTHLAKE HOSPITALISTS LLC

Provider Business Mailing Address
First Line	:	PO BOX 92941
Second Line	:
City	:	SOUTHLAKE
State	:	TX
Zip	:	76092-0941
Country	:	US
Telephone Number	:	817-521-4747
Fax Number	:	214-279-9273

Provider Business Practice Location Address
First Line	:	1321 BAY MEADOWS DR
Second Line	:
City	:	SOUTHLAKE
State	:	TX
Zip	:	76092-3938
Country	:	US
Telephone Number	:	817-521-4747
Fax Number	:	214-279-9273

Authorized Official
Title or Position	:	OWNER
Name	:	ELIZABETH M CHANDY
Credential	:	DO
Telephone Number	:	817-521-4747

Provider Enumeration Date	:	04/29/2016
Last Update Date	:	04/29/2016

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