MEDICARE: PREFERRED DOCTORS ALLIANCE, LLC

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	302F00000X	Exclusive Provider Organization

General Provider Information

NPI Number	:	1780014266
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PREFERRED DOCTORS ALLIANCE, LLC

Provider Business Mailing Address
First Line	:	1050 S 11TH ST
Second Line	:
City	:	BEAUMONT
State	:	TX
Zip	:	77701-4739
Country	:	US
Telephone Number	:	409-832-7195
Fax Number	:

Provider Business Practice Location Address
First Line	:	1050 S 11TH ST
Second Line	:
City	:	BEAUMONT
State	:	TX
Zip	:	77701-4739
Country	:	US
Telephone Number	:	409-832-7195
Fax Number	:	409-892-5939

Authorized Official
Title or Position	:	CEO
Name	:	SHAMA P QURAISHI
Credential	:	M.D.
Telephone Number	:	409-832-7195

Provider Enumeration Date	:	11/19/2013
Last Update Date	:	11/19/2013

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