MEDICARE: CENTENNIAL OB GYN PA

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	207V00000X	Obstetrics & Gynecology Physician

General Provider Information

NPI Number	:	1659354603
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CENTENNIAL OB GYN PA

Provider Business Mailing Address
First Line	:	5757 WARREN PKWY
Second Line	:	SUITE 210
City	:	FRISCO
State	:	TX
Zip	:	75034-4274
Country	:	US
Telephone Number	:	972-731-6565
Fax Number	:	972-731-6570

Provider Business Practice Location Address
First Line	:	5757 WARREN PKWY
Second Line	:	SUITE 210
City	:	FRISCO
State	:	TX
Zip	:	75034-4274
Country	:	US
Telephone Number	:	972-731-6565
Fax Number	:	972-731-6570

Authorized Official
Title or Position	:	PRACTICE MANAGER
Name	:	MRS. KAREN KAY BAUSONE
Credential	:
Telephone Number	:	972-731-6565

Provider Enumeration Date	:	11/23/2005
Last Update Date	:	10/05/2016

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