Basic Information
| Provider Information | |||||||||
| NPI: | 1659354603 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CENTENNIAL OB GYN PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5757 WARREN PKWY | ||||||||
| Address2: | SUITE 210 | ||||||||
| City: | FRISCO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 750344274 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9727316565 | ||||||||
| FaxNumber: | 9727316570 | ||||||||
| Practice Location | |||||||||
| Address1: | 5757 WARREN PKWY | ||||||||
| Address2: | SUITE 210 | ||||||||
| City: | FRISCO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 750344274 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9727316565 | ||||||||
| FaxNumber: | 9727316570 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/23/2005 | ||||||||
| LastUpdateDate: | 10/05/2016 | ||||||||
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| AuthorizedOfficialLastName: | BAUSONE | ||||||||
| AuthorizedOfficialFirstName: | KAREN | ||||||||
| AuthorizedOfficialMiddleName: | KAY | ||||||||
| AuthorizedOfficialTitleorPosition: | PRACTICE MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 9727316565 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207V00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology |
No ID Information.