1538412895 NPI number — COVENANT MEDICAL GROUP

Table of content: (NPI 1538412895)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1538412895 NPI number — COVENANT MEDICAL GROUP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
COVENANT MEDICAL GROUP
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:
1538412895
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/23/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2215 NASHVILLE AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LUBBOCK
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
79410-1105
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
806-725-5844
Provider Business Mailing Address Fax Number:
806-723-6532

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
409 8TH ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ABERNATHY
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
79311-3416
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
806-298-5884
Provider Business Practice Location Address Fax Number:
806-298-5889
Provider Enumeration Date:
10/23/2012

Additional Information

Authorized Official

Authorized Official Last Name:
KOTHMANN
Authorized Official First Name:
KRISTEN
Authorized Official Middle Name:
Authorized Official Title or Position:
COO/VP
Authorized Official Telephone Number:
806-725-7800

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 261QR1300X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 673910 . This is a "MEDICARE" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 328182601 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".




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