1609986546 NPI number — EDWARD MICHAEL MCTAGUE PT, DPT, OCS

Table of content: EDWARD MICHAEL MCTAGUE PT, DPT, OCS (NPI 1609986546)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1609986546 NPI number — EDWARD MICHAEL MCTAGUE PT, DPT, OCS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MCTAGUE
Provider First Name:
EDWARD
Provider Middle Name:
MICHAEL
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PT, DPT, OCS
Provider Gender Code:
M

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:
1609986546
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/13/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
17325 BELL NORTH DR
Provider Second Line Business Mailing Address:
SUITE 2B
Provider Business Mailing Address City Name:
SCHERTZ
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
78154-3368
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
888-590-4002
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
204 S INTERSTATE 35
Provider Second Line Business Practice Location Address:
STE: 203
Provider Business Practice Location Address City Name:
GEORGETOWN
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
78628-4126
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
512-863-7761
Provider Business Practice Location Address Fax Number:
512-863-0973
Provider Enumeration Date:
08/30/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 225100000X , with the licence number:  1216710 , 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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