MEDICARE: 2013 PEARL ER PHYSICIANS 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	207PE0004X	Emergency Medical Services (Emergency Medicine) Physician

General Provider Information

NPI Number	:	1255841011
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	2013 PEARL ER PHYSICIANS PLLC

Provider Business Mailing Address
First Line	:	PO BOX 93044
Second Line	:
City	:	SOUTHLAKE
State	:	TX
Zip	:	76092-1044
Country	:	US
Telephone Number	:	817-527-3403
Fax Number	:

Provider Business Practice Location Address
First Line	:	2015 BROADWAY ST
Second Line	:
City	:	SAN ANTONIO
State	:	TX
Zip	:	78215-1117
Country	:	US
Telephone Number	:	817-527-3403
Fax Number	:	817-527-3445

Authorized Official
Title or Position	:	GENERAL COUSEL
Name	:	JOHN B NEIMAN
Credential	:
Telephone Number	:	817-421-0034

Provider Enumeration Date	:	10/06/2017
Last Update Date	:	10/06/2017

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