MEDICARE: GLAUCOMA ASSOCIATES OF TEXAS 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	207W00000X	Ophthalmology Physician

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	00TS72	OTHER	TX	BCBS

General Provider Information

NPI Number	:	1679678239
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GLAUCOMA ASSOCIATES OF TEXAS PA

Provider Business Mailing Address
First Line	:	PO BOX 730475
Second Line	:
City	:	DALLAS
State	:	TX
Zip	:	75373-0475
Country	:	US
Telephone Number	:	972-791-1224
Fax Number	:	972-819-0050

Provider Business Practice Location Address
First Line	:	7150 GREENVILLE AVE
Second Line	:	SUITE 300
City	:	DALLAS
State	:	TX
Zip	:	75231-7900
Country	:	US
Telephone Number	:	214-360-0000
Fax Number	:	214-360-0083

Authorized Official
Title or Position	:	PRESIDENT
Name	:	RONALD L FELLMAN
Credential	:	MD
Telephone Number	:	214-360-0000

Provider Enumeration Date	:	09/14/2006
Last Update Date	:	12/12/2007

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