1760483770 NPI number — ELLINGTON MEMORIAL CLINIC, LLP

Table of content: (NPI 1760483770)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1760483770 NPI number — ELLINGTON MEMORIAL CLINIC, LLP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ELLINGTON MEMORIAL CLINIC, LLP
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:
ELLINGTON RURAL HEALTH CLINIC
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:
1760483770
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/21/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1011 SOUTH WILLIAMS STREET
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ATLANTA
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
75551-3245
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
903-796-2868
Provider Business Mailing Address Fax Number:
903-796-0826

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1011 SOUTH WILLIAMS STREET
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ATLANTA
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
75551-3245
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
903-796-2868
Provider Business Practice Location Address Fax Number:
903-796-0826
Provider Enumeration Date:
08/02/2005

Additional Information

Authorized Official

Authorized Official Last Name:
CARNEY
Authorized Official First Name:
ANITA
Authorized Official Middle Name:
G
Authorized Official Title or Position:
OFFICE MGR
Authorized Official Telephone Number:
903-796-2868

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 261QR1300X , 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: 04709 . This is a "BCBS" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 133389002 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 133389004 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 88966 . This is a "BCBS" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 133389005 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".




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