MEDICARE: GI MD TX PLLC

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

General Provider Information

NPI Number	:	1174111058
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GI MD TX PLLC

Provider Business Mailing Address
First Line	:	960 RIDGEVIEW DR STE 140
Second Line	:
City	:	ALLEN
State	:	TX
Zip	:	75013-5543
Country	:	US
Telephone Number	:	214-390-7697
Fax Number	:	972-432-6692

Provider Business Practice Location Address
First Line	:	5000 ALICIA DR
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76133-7902
Country	:	US
Telephone Number	:	214-390-7697
Fax Number	:	972-432-6692

Authorized Official
Title or Position	:	ADMIN
Name	:	ROBERT GROYSMAN
Credential	:
Telephone Number	:	214-390-7697

Provider Enumeration Date	:	01/06/2021
Last Update Date	:	04/15/2021

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