MEDICARE: NATIONWIDE NEURO HEALTH, 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	2084S0012X	Sleep Medicine (Psychiatry & Neurology) Physician

General Provider Information

NPI Number	:	1174946636
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	NATIONWIDE NEURO HEALTH, PLLC

Provider Business Mailing Address
First Line	:	1825 S KIMBALL AVE
Second Line	:
City	:	CALDWELL
State	:	ID
Zip	:	83605-4828
Country	:	US
Telephone Number	:	208-454-0567
Fax Number	:	208-402-6635

Provider Business Practice Location Address
First Line	:	6430 HILLCROFT ST
Second Line	:	100-A
City	:	HOUSTON
State	:	TX
Zip	:	77081-3191
Country	:	US
Telephone Number	:	972-526-5444
Fax Number	:	972-526-5445

Authorized Official
Title or Position	:	PRESIDENT
Name	:	WADE S HARRIS
Credential	:	MD
Telephone Number	:	208-454-0567

Provider Enumeration Date	:	02/03/2014
Last Update Date	:	02/03/2014

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