1609041888 NPI number — BURROUGHS MEDICAL CLINIC, PA

Table of content: (NPI 1609041888)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1609041888 NPI number — BURROUGHS MEDICAL CLINIC, PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BURROUGHS MEDICAL CLINIC, 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:
1609041888
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/08/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 2730
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
GLEN ROSE
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
76043-2730
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
254-897-3310
Provider Business Mailing Address Fax Number:
254-897-9973

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1008 NE BIG BEND TRL
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
GLEN ROSE
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
76043-4912
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
254-897-3310
Provider Business Practice Location Address Fax Number:
254-897-9973
Provider Enumeration Date:
04/28/2008

Additional Information

Authorized Official

Authorized Official Last Name:
BURROUGHS
Authorized Official First Name:
KAREN
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
254-897-3310

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , with the licence number:  J1901 , 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: 0097RH . This is a "BLUE CROSS BLUE SHIELD TEXAS" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".




Copyright © 2007-2025 www.npivalidator.com