MEDICARE: MODERN GYNECOLOGY, 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	207VG0400X	Gynecology Physician	M3682	TX

General Provider Information

NPI Number	:	1982953469
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MODERN GYNECOLOGY, PLLC

Provider Business Mailing Address
First Line	:	3822 BOWSER AVE.
Second Line	:
City	:	DALLAS
State	:	TX
Zip	:	75219-4301
Country	:	US
Telephone Number	:	214-604-5440
Fax Number	:

Provider Business Practice Location Address
First Line	:	3822 BOWSER AVE.
Second Line	:
City	:	DALLAS
State	:	TX
Zip	:	75219-4301
Country	:	US
Telephone Number	:	214-604-5440
Fax Number	:

Authorized Official
Title or Position	:	MANAGER/ PRESIDENT
Name	:	DR. AMIT INDRAVADAN PATEL
Credential	:	M.D.
Telephone Number	:	214-604-5440

Provider Enumeration Date	:	08/30/2012
Last Update Date	:	08/30/2012

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