MEDICARE: PERMIAN BASIN ER IV

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	261QE0002X	Emergency Care Clinic/Center

General Provider Information

NPI Number	:	1306222385
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PERMIAN BASIN ER IV

Provider Business Mailing Address
First Line	:	4157 BUFFALO GAP RD
Second Line	:
City	:	ABILENE
State	:	TX
Zip	:	79605-7233
Country	:	US
Telephone Number	:	281-658-1078
Fax Number	:

Provider Business Practice Location Address
First Line	:	4157 BUFFALO GAP RD
Second Line	:
City	:	ABILENE
State	:	TX
Zip	:	79605-7233
Country	:	US
Telephone Number	:	281-658-1078
Fax Number	:

Authorized Official
Title or Position	:	MANAGER
Name	:	DR. CHRISTOPHER KWON
Credential	:	M.D.
Telephone Number	:	281-658-1078

Provider Enumeration Date	:	08/03/2015
Last Update Date	:	08/03/2015

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