MEDICARE: JPS PHYSICIAN GROUP INC.

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	208M00000X	Hospitalist Physician

General Provider Information

NPI Number	:	1073761805
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	JPS PHYSICIAN GROUP INC.

Provider Business Mailing Address
First Line	:	19801 ANITA AVE
Second Line	:
City	:	CASTRO VALLEY
State	:	CA
Zip	:	94546-4103
Country	:	US
Telephone Number	:	650-743-6473
Fax Number	:

Provider Business Practice Location Address
First Line	:	1617 HEMPHILL ST
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76104-4709
Country	:	US
Telephone Number	:	817-852-8440
Fax Number	:	817-927-3603

Authorized Official
Title or Position	:	EXECUTIVE DIRECTOR
Name	:	MR. CORBIN WILSON
Credential	:
Telephone Number	:	817-921-3431

Provider Enumeration Date	:	09/04/2008
Last Update Date	:	09/04/2008

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