MEDICARE: MEDALL, INC.

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	332BX2000X	Oxygen Equipment & Supplies (DME)	5468630001	TX
2	332B00000X	Durable Medical Equipment & Medical Supplies	5468630001	TX

Other Identifiers

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

General Provider Information

NPI Number	:	1649204694
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MEDALL, INC.

Provider Business Mailing Address
First Line	:	PO BOX 185132
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76181-0132
Country	:	US
Telephone Number	:	817-626-9991
Fax Number	:	817-626-0920

Provider Business Practice Location Address
First Line	:	221 W EXCHANGE AVE
Second Line	:	SUITE 303
City	:	FORT WORTH
State	:	TX
Zip	:	76164-9614
Country	:	US
Telephone Number	:	817-626-9991
Fax Number	:	817-626-0920

Authorized Official
Title or Position	:	PRESIDENT
Name	:	MIKE SCOTT WILBURN
Credential	:	OP
Telephone Number	:	817-626-9991

Provider Enumeration Date	:	07/10/2006
Last Update Date	:	08/08/2008

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Directions to “MEDALL, INC. ” Practice Location

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