MEDICARE: DR. JACK BRIDGES BANKHEAD M.D.

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	207R00000X	Internal Medicine Physician	D6939	TX

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	110160026	OTHER	TX	RR MEDICARE

Other Identifiers

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

General Provider Information

NPI Number	:	1619080728
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JACK BRIDGES BANKHEAD M.D.

Provider Business Mailing Address
First Line	:	4708 ALLIANCE BLVD STE 300
Second Line	:	BAYLOR MEDICAL PLAZA 1
City	:	PLANO
State	:	TX
Zip	:	75093-5339
Country	:	US
Telephone Number	:	972-758-6000
Fax Number	:	972-758-6001

Provider Business Practice Location Address
First Line	:	4708 ALLIANCE BLVD STE 300
Second Line	:	BAYLOR MEDICAL PLAZA 1
City	:	PLANO
State	:	TX
Zip	:	75093-5339
Country	:	US
Telephone Number	:	972-758-6000
Fax Number	:	972-758-6001

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/16/2006
Last Update Date	:	06/29/2008

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Directions to “ DR. JACK BRIDGES BANKHEAD M.D.” Practice Location

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