MEDICARE: NEUROMUSCULOSKELETAL REHABILITATION MEDICINE CONSULTANT

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	208100000X	Physical Medicine & Rehabilitation Physician

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	0056WD	OTHER	TX	BCBS

General Provider Information

NPI Number	:	1265495816
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	NEUROMUSCULOSKELETAL REHABILITATION MEDICINE CONSULTANT

Provider Business Mailing Address
First Line	:	7750 N MACARTHUR BLVD
Second Line	:	STE 120-338
City	:	IRVING
State	:	TX
Zip	:	75063-7514
Country	:	US
Telephone Number	:	817-284-9850
Fax Number	:	949-863-6838

Provider Business Practice Location Address
First Line	:	3600 MAPLESHADE LN
Second Line	:
City	:	PLANO
State	:	TX
Zip	:	75075-5715
Country	:	US
Telephone Number	:	972-849-0164
Fax Number	:	972-999-4634

Authorized Official
Title or Position	:	VP OPERATIONS
Name	:	LISA M LEE
Credential	:
Telephone Number	:	817-284-9850

Provider Enumeration Date	:	04/06/2006
Last Update Date	:	11/25/2024

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