MEDICARE: TEXAS DIGESTIVE DISEASE CONSULTANTS, 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	291U00000X	Clinical Medical Laboratory	45D1067054	TX

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1275739815
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	TEXAS DIGESTIVE DISEASE CONSULTANTS, PLLC

Provider Business Mailing Address
First Line	:	PO BOX 35629
Second Line	:
City	:	DALLAS
State	:	TX
Zip	:	75235-0629
Country	:	US
Telephone Number	:	214-424-2200
Fax Number	:	214-231-2159

Provider Business Practice Location Address
First Line	:	1800 PLAZA DR
Second Line	:
City	:	BEDFORD
State	:	TX
Zip	:	76021-6013
Country	:	US
Telephone Number	:	817-310-4490
Fax Number	:	817-310-4491

Authorized Official
Title or Position	:	SVP, PAYER RELATIONS
Name	:	STEPHANIE SUMMERALL
Credential	:
Telephone Number	:	214-424-2200

Provider Enumeration Date	:	06/21/2007
Last Update Date	:	06/21/2022

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