MEDICARE: GLOBAL BRAIN EEG

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	293D00000X	Physiological Laboratory		TX

General Provider Information

NPI Number	:	1568982148
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GLOBAL BRAIN EEG

Provider Business Mailing Address
First Line	:	521 W SOUTHLAKE BLVD STE 100
Second Line	:
City	:	SOUTHLAKE
State	:	TX
Zip	:	76092-6173
Country	:	US
Telephone Number	:	817-328-3000
Fax Number	:	817-328-3333

Provider Business Practice Location Address
First Line	:	521 W SOUTHLAKE BLVD STE 100
Second Line	:
City	:	SOUTHLAKE
State	:	TX
Zip	:	76092-6173
Country	:	US
Telephone Number	:	817-328-3000
Fax Number	:	817-328-3333

Authorized Official
Title or Position	:	OWNER
Name	:	HEIDI DENISE HOLLINGSWORH
Credential	:
Telephone Number	:	817-798-7763

Provider Enumeration Date	:	06/23/2017
Last Update Date	:	07/21/2022

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