1003825852 NPI number — FMC MEDICAL FOUNDATION, INC

Table of content: (NPI 1003825852)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1003825852 NPI number — FMC MEDICAL FOUNDATION, INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
FMC MEDICAL FOUNDATION, INC
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:
PANHANDLE PEDIATRIC GROUP P A
Provider Other Organization Name Type Code:
4
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:
1003825852
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/19/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1500 S COULTER ST STE 1
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
AMARILLO
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
79106-1787
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
806-354-0404
Provider Business Mailing Address Fax Number:
806-354-2810

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1500 S COULTER ST STE 1
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
AMARILLO
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
79106-1787
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
806-354-0404
Provider Business Practice Location Address Fax Number:
806-354-2810
Provider Enumeration Date:
08/07/2006

Additional Information

Authorized Official

Authorized Official Last Name:
FEEMSTER
Authorized Official First Name:
STEFANIE
Authorized Official Middle Name:
Authorized Official Title or Position:
CREDENTIALING SPECIALIST
Authorized Official Telephone Number:
806-358-9400

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 208000000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 363A00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363L00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 081138203 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 134071303 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 081138202 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 081138201 TERM 12/16 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 0077BM . This is a "BCBS" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".




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