MEDICARE: DR. KIRAT SANTANU GHOSH M.D.

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	207Q00000X	Family Medicine Physician	L3657	TX

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
2	080184128	OTHER	TX	RR MEDICARE

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	8F3456	OTHER	TN	BCBS

General Provider Information

NPI Number	:	1104854926
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. KIRAT SANTANU GHOSH M.D.

Provider Business Mailing Address
First Line	:	13350 TI BLVD
Second Line	:	MS327
City	:	DALLAS
State	:	TX
Zip	:	75243-1512
Country	:	US
Telephone Number	:	972-671-9504
Fax Number	:	972-671-7096

Provider Business Practice Location Address
First Line	:	13350 TI BLVD
Second Line	:	M/S 327
City	:	DALLAS
State	:	TX
Zip	:	75243-1512
Country	:	US
Telephone Number	:	972-671-9504
Fax Number	:	972-671-7096

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

Provider Enumeration Date	:	06/29/2006
Last Update Date	:	07/28/2009

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