1174556187 NPI number — FAMILY MEDICINE CENTER OF PAMPA PLLC

Table of content: (NPI 1174556187)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1174556187 NPI number — FAMILY MEDICINE CENTER OF PAMPA PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
FAMILY MEDICINE CENTER OF PAMPA PLLC
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:
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:
1174556187
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3023 PERRYTON PKWY
Provider Second Line Business Mailing Address:
SUITE 101
Provider Business Mailing Address City Name:
PAMPA
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
79065-2817
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
806-665-0801
Provider Business Mailing Address Fax Number:
806-665-8503

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3023 PERRYTON PKWY
Provider Second Line Business Practice Location Address:
SUITE 101
Provider Business Practice Location Address City Name:
PAMPA
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
79065-2821
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
806-665-0801
Provider Business Practice Location Address Fax Number:
806-665-8503
Provider Enumeration Date:
07/10/2006

Additional Information

Authorized Official

Authorized Official Last Name:
CRAWFORD
Authorized Official First Name:
KATHY
Authorized Official Middle Name:
Authorized Official Title or Position:
ADMINISTRATOR
Authorized Official Telephone Number:
806-665-0801

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 207R00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 208600000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363LF0000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 83668601 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: R17034 . This is a "RADIOLOGY" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 00L20L . This is a "BCBS" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 45D0864498 . This is a "CLIA" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 00L20L . This is a "RAILROAD MEDICARE GROUP" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".




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