MEDICARE: INTEGRATED MEDICAL PROFESSIONALS 1, LTD

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	207L00000X	Anesthesiology Physician

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	00185Y	OTHER	TX	MEDICARE

General Provider Information

NPI Number	:	1336160209
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	INTEGRATED MEDICAL PROFESSIONALS 1, LTD

Provider Business Mailing Address
First Line	:	2120 MISTLETOE BLVD UNIT 2
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76110-1174
Country	:	US
Telephone Number	:	817-927-8900
Fax Number	:	817-927-8902

Provider Business Practice Location Address
First Line	:	2120 MISTLETOE BLVD UNIT 2
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76110-1174
Country	:	US
Telephone Number	:	817-927-8900
Fax Number	:	817-927-8902

Authorized Official
Title or Position	:	ADMINISTRATOR
Name	:	MS. SHERI HUMPHREYS
Credential	:
Telephone Number	:	817-927-8900

Provider Enumeration Date	:	07/23/2006
Last Update Date	:	03/10/2011

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