MEDICARE: BRAD WYSONG MD PA

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	2085R0202X	Diagnostic Radiology Physician

General Provider Information

NPI Number	:	1235373150
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BRAD WYSONG MD PA

Provider Business Mailing Address
First Line	:	PO BOX 740968
Second Line	:
City	:	DALLAS
State	:	TX
Zip	:	75374-0968
Country	:	US
Telephone Number	:	800-945-2455
Fax Number	:	469-742-0771

Provider Business Practice Location Address
First Line	:	130 S CENTRAL EXPY
Second Line	:
City	:	MCKINNEY
State	:	TX
Zip	:	75070-3742
Country	:	US
Telephone Number	:	972-548-5308
Fax Number	:	972-548-5433

Authorized Official
Title or Position	:	MD
Name	:	CHARLES B WYSONG
Credential	:	MD
Telephone Number	:	972-548-5308

Provider Enumeration Date	:	04/22/2009
Last Update Date	:	07/30/2009

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