1790940633 NPI number — PHYLLIS MCLEMORE NP

Table of content: PHYLLIS MCLEMORE NP (NPI 1790940633)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1790940633 NPI number — PHYLLIS MCLEMORE NP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MCLEMORE
Provider First Name:
PHYLLIS
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
NP
Provider Gender Code:
F

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:
1790940633
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/09/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1400 WALLACE BLVD
Provider Second Line Business Mailing Address:
ATTN: CREDENTIALING DEPT
Provider Business Mailing Address City Name:
AMARILLO
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
79106-1708
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
806-354-5585
Provider Business Mailing Address Fax Number:
806-356-4673

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1901 MEDI PARK
Provider Second Line Business Practice Location Address:
STE 2051
Provider Business Practice Location Address City Name:
AMARILLO
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
79106-2169
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
806-468-4600
Provider Business Practice Location Address Fax Number:
806-468-4398
Provider Enumeration Date:
07/21/2008

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: 363L00000X , with the licence number:  517550 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 364SP0200X , with the licence number: 517550 , 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: 042483005 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 200322680 A , issued by the state of ( OK ) . This identifiers is of the category "MEDICAID".
  • Identifier: 042483006 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 05572568 , issued by the state of ( NM ) . This identifiers is of the category "MEDICAID".




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