1093982290 NPI number — ZAPATA MEDICAL CLINIC

Table of content: (NPI 1093982290)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1093982290 NPI number — ZAPATA MEDICAL CLINIC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ZAPATA MEDICAL CLINIC
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:
PHYNET, INC.
Provider Other Organization Name Type Code:
5
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:
1093982290
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/23/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4002 TECHNOLOGY CTR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LONGVIEW
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
75605-2697
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
903-247-0484
Provider Business Mailing Address Fax Number:
903-247-0485

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
316 N HENDERSON BLVD
Provider Second Line Business Practice Location Address:
STE A
Provider Business Practice Location Address City Name:
KILGORE
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
75662-2712
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
903-984-2145
Provider Business Practice Location Address Fax Number:
903-984-8361
Provider Enumeration Date:
05/15/2008

Additional Information

Authorized Official

Authorized Official Last Name:
FORD
Authorized Official First Name:
JOHN
Authorized Official Middle Name:
D.
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
903-247-0484

Provider Taxonomy Codes

  • Taxonomy code: 261QH0100X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 159694201 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".




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