1215013511 NPI number — WEST TEXAS INTERNAL MEDICINE CLINIC

Table of content: (NPI 1215013511)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1215013511 NPI number — WEST TEXAS INTERNAL MEDICINE CLINIC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
WEST TEXAS INTERNAL MEDICINE 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:
JIM J. GUERRA M.D.
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:
1215013511
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/03/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
7100 OAKMONT BLVD
Provider Second Line Business Mailing Address:
SUITE 105
Provider Business Mailing Address City Name:
FORT WORTH
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
76132-3900
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
817-292-2700
Provider Business Mailing Address Fax Number:
817-292-9806

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
7100 OAKMONT BLVD
Provider Second Line Business Practice Location Address:
SUITE 105
Provider Business Practice Location Address City Name:
FORT WORTH
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
76132-3900
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
817-292-2700
Provider Business Practice Location Address Fax Number:
817-292-9806
Provider Enumeration Date:
10/29/2006

Additional Information

Authorized Official

Authorized Official Last Name:
GUERRA
Authorized Official First Name:
JIM
Authorized Official Middle Name:
J
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
817-292-2700

Provider Taxonomy Codes

  • Taxonomy code: 174400000X , with the licence number:  J2590 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 0040JK . This is a "BCBS GROUP NUMBER" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 9399591007 . This is a "CIGNA NUMBER" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 2543029 . This is a "AETNA NUMBER" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".




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