MEDICARE: RICHARD JACKSON PAYNE MD

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	174400000X	Specialist	K1617	TX
2	207L00000X	Anesthesiology Physician	K1617	TX

General Provider Information

NPI Number	:	1245235092
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	RICHARD JACKSON PAYNE MD

Provider Business Mailing Address
First Line	:	2602 SAINT MICHAEL DR
Second Line	:	SUITE 301
City	:	TEXARKANA
State	:	TX
Zip	:	75503-2387
Country	:	US
Telephone Number	:	903-614-5258
Fax Number	:	903-614-5260

Provider Business Practice Location Address
First Line	:	2602 SAINT MICHAEL DR
Second Line	:	SUITE 301
City	:	TEXARKANA
State	:	TX
Zip	:	75503-2387
Country	:	US
Telephone Number	:	903-614-5258
Fax Number	:	903-614-5260

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

Provider Enumeration Date	:	06/17/2005
Last Update Date	:	02/24/2020

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