1174538623 NPI number — PODIATRY OF CENTRAL TEXAS PA

Table of content: (NPI 1174538623)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1174538623 NPI number — PODIATRY OF CENTRAL TEXAS PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PODIATRY OF CENTRAL TEXAS PA
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:
Provider Other Organization Name Type Code:
6
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:
1174538623
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/30/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 496
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
HUBBARD
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
76648-0496
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
800-957-9971
Provider Business Mailing Address Fax Number:
888-878-2856

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
701 MCCLINTIC DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
GROESBECK
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
76642-2128
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
800-957-9971
Provider Business Practice Location Address Fax Number:
888-878-2856
Provider Enumeration Date:
07/30/2006

Additional Information

Authorized Official

Authorized Official Last Name:
BATTLES
Authorized Official First Name:
BRIAN
Authorized Official Middle Name:
DAVID
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
800-957-9971

Provider Taxonomy Codes

  • Taxonomy code: 213ES0103X , with the licence number:  1771 , 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: 0026NV . This is a "BCBS" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 188679801 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 194386201 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 194386202 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".




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