MEDICARE: PHILLIP T EVANS D.O.

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	207L00000X	Anesthesiology Physician	F8857	TX

General Provider Information

NPI Number	:	1144231887
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	PHILLIP T EVANS D.O.

Provider Business Mailing Address
First Line	:	PO BOX 11219
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76110-0219
Country	:	US
Telephone Number	:	817-294-7444
Fax Number	:	817-294-7172

Provider Business Practice Location Address
First Line	:	12001 S. FWY
Second Line	:	SUITE 101
City	:	BURLESON
State	:	TX
Zip	:	76028
Country	:	US
Telephone Number	:	817-615-4400
Fax Number	:

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

Provider Enumeration Date	:	08/10/2006
Last Update Date	:	07/08/2007

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