1053464982 NPI number — FREDERICKSBURG FAMILY CLINIC PA

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1053464982 NPI number — FREDERICKSBURG FAMILY CLINIC PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
FREDERICKSBURG FAMILY CLINIC PA
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
CORNERSTONE CLINIC AT COMFORT
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1053464982
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/25/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
514 W WINDCREST ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FREDERICKSBURG
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
78624-4633
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
830-997-0330
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
815 FRONT ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
COMFORT
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
78013
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
830-995-5633
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
01/22/2007

Additional Information

Authorized Official

Authorized Official Last Name:
DONAHY
Authorized Official First Name:
CATHY
Authorized Official Middle Name:
Authorized Official Title or Position:
OFFICE MANAGER
Authorized Official Telephone Number:
830-997-0330

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 0009QH . This is a "BCBSTX" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 189877703 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: DG7779 . This is a "MEDICARE RAILROAD" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 189877702 . This is a "MEDICAID EPSDT" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".




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