MEDICARE: PRISM ORTHOPEDIC

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	207XS0117X	Orthopaedic Surgery of the Spine Physician	N7365	TX

General Provider Information

NPI Number	:	1386037273
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PRISM ORTHOPEDIC

Provider Business Mailing Address
First Line	:	PO BOX 674074
Second Line	:
City	:	DALLAS
State	:	TX
Zip	:	75267-4074
Country	:	US
Telephone Number	:	214-396-3936
Fax Number	:	888-624-8659

Provider Business Practice Location Address
First Line	:	7712 SAN JACINTO PL STE 200
Second Line	:
City	:	PLANO
State	:	TX
Zip	:	75024-3212
Country	:	US
Telephone Number	:	214-378-4661
Fax Number	:	888-624-8659

Authorized Official
Title or Position	:	CREDENTIAL COORDINATOR
Name	:	MISS BRANDY BARROW
Credential	:
Telephone Number	:	214-378-4661

Provider Enumeration Date	:	03/17/2015
Last Update Date	:	06/09/2015

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Directions to “PRISM ORTHOPEDIC ” Practice Location

Language	Start Address	Practice Location

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