1366694028 NPI number — CRAIG RANCH FAMILY MEDICINE, PA

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1366694028 NPI number — CRAIG RANCH FAMILY MEDICINE, PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CRAIG RANCH FAMILY MEDICINE, 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:
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:
1366694028
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/10/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
8080 STATE HIGHWAY 121
Provider Second Line Business Mailing Address:
SUITE 350
Provider Business Mailing Address City Name:
MCKINNEY
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
75070-2900
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
972-908-2727
Provider Business Mailing Address Fax Number:
972-908-2728

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
8080 STATE HIGHWAY 121
Provider Second Line Business Practice Location Address:
SUITE 350
Provider Business Practice Location Address City Name:
MCKINNEY
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
75070-2900
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
972-908-2727
Provider Business Practice Location Address Fax Number:
972-908-2728
Provider Enumeration Date:
10/14/2008

Additional Information

Authorized Official

Authorized Official Last Name:
THIELEN
Authorized Official First Name:
MAURA
Authorized Official Middle Name:
Authorized Official Title or Position:
MEMBER
Authorized Official Telephone Number:
972-908-2727

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , with the licence number:  L0647 , 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)





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