1962424846 NPI number — PILOT POINT MEDICAL CLINIC, P.A.

Table of content: (NPI 1962424846)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1962424846 NPI number — PILOT POINT MEDICAL CLINIC, P.A.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PILOT POINT MEDICAL CLINIC, P.A.
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:
KENNETH W. BERESFORD, M.D., 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:
1962424846
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/12/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 1117
Provider Second Line Business Mailing Address:
1246 HWY 377 SOUTH SUITE 200
Provider Business Mailing Address City Name:
PILOT POINT
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
76258-1117
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
940-686-2254
Provider Business Mailing Address Fax Number:
940-686-2830

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1246 S HIGHWAY 377
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PILOT POINT
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
76258-4375
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
940-686-2254
Provider Business Practice Location Address Fax Number:
940-686-2830
Provider Enumeration Date:
07/23/2006

Additional Information

Authorized Official

Authorized Official Last Name:
BERESFORD
Authorized Official First Name:
KENNETH
Authorized Official Middle Name:
WAYNE
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
940-686-2254

Provider Taxonomy Codes

  • Taxonomy code: 261QP2300X , with the licence number:  K9226 , 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: 045386202 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 0A3440 . This is a "MEDICARE GROUP PTAN" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 8F20689 . This is a "MEDICARE INDIV PTAN INDVID NPI" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 0A3440 . This is a "MEDICARE INDIVID PTAN FOR GRP NPI" identifier . This identifiers is of the category "OTHER".




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