MEDICARE: TEXAS MODERN GASTROENTEROLOGY

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	207RG0100X	Gastroenterology Physician

General Provider Information

NPI Number	:	1902494743
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	TEXAS MODERN GASTROENTEROLOGY

Provider Business Mailing Address
First Line	:	1216 CHURCH ST
Second Line	:
City	:	SULPHUR SPRINGS
State	:	TX
Zip	:	75482-2108
Country	:	US
Telephone Number	:	903-588-2222
Fax Number	:	903-588-2225

Provider Business Practice Location Address
First Line	:	1216 CHURCH ST
Second Line	:
City	:	SULPHUR SPRINGS
State	:	TX
Zip	:	75482-2108
Country	:	US
Telephone Number	:	903-588-2222
Fax Number	:	903-588-2225

Authorized Official
Title or Position	:	PHYSICIAN OWNER/PHYSICIAN
Name	:	DR. VIVIAN SAMI EBRAHIM
Credential	:	MD
Telephone Number	:	214-729-0111

Provider Enumeration Date	:	01/07/2021
Last Update Date	:	01/23/2024

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Directions to “TEXAS MODERN GASTROENTEROLOGY ” Practice Location

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