MEDICARE: CENTRAL TEXAS MEDICAL SERVICES PLLC

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	261QU0200X	Urgent Care Clinic/Center	N0664	TX

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	N0664	OTHER	TX	MEDICAL LICENCE

General Provider Information

NPI Number	:	1891067914
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CENTRAL TEXAS MEDICAL SERVICES PLLC

Provider Business Mailing Address
First Line	:	PO BOX 543539
Second Line	:
City	:	GRAND PRAIRIE
State	:	TX
Zip	:	75054-3539
Country	:	US
Telephone Number	:	214-870-8133
Fax Number	:	817-592-3025

Provider Business Practice Location Address
First Line	:	7227 CANA
Second Line	:
City	:	GRAND PRAIRIE
State	:	TX
Zip	:	75054-6860
Country	:	US
Telephone Number	:	214-870-8133
Fax Number	:	817-592-3025

Authorized Official
Title or Position	:	MEMBER
Name	:	DEANDRE BROWN
Credential	:	MD
Telephone Number	:	214-870-8133

Provider Enumeration Date	:	02/04/2012
Last Update Date	:	02/04/2012

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