Basic Information
| Provider Information | |||||||||
| NPI: | 1093743783 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | FALLS COMMUNITY HOSPITAL AND CLINIC | ||||||||
| LastName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | THE DOCTOR CLINIC | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 60 | ||||||||
| Address2: | |||||||||
| City: | MARLIN | ||||||||
| State: | TX | ||||||||
| PostalCode: | 766610060 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2548033561 | ||||||||
| FaxNumber: | 2548836066 | ||||||||
| Practice Location | |||||||||
| Address1: | 322 COLEMAN ST. | ||||||||
| Address2: | |||||||||
| City: | MARLIN | ||||||||
| State: | TX | ||||||||
| PostalCode: | 766600060 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2548033561 | ||||||||
| FaxNumber: | 2548836066 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/29/2006 | ||||||||
| LastUpdateDate: | 07/06/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | LYLE | ||||||||
| AuthorizedOfficialFirstName: | JEFF | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | ADMINISTRATOR | ||||||||
| AuthorizedOfficialTelephone: | 2548033561 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | FALLS COMMUNITY HOSPITAL AND CLINIC | ||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 07/06/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103T00000X | 24850 | TX | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Psychologist | 111N00000X | 8240 | TX | N | 193200000X MULTI-SPECIALTY GROUP | Chiropractic Providers | Chiropractor | 207P00000X | J0919 | TX | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Emergency Medicine | 207P00000X | E0892 | TX | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Emergency Medicine | 207Y00000X | J5638 | TX | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Otolaryngology | 208600000X | D3139 | TX | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Surgery | 213E00000X | G1558 | TX | N | 193200000X MULTI-SPECIALTY GROUP | Podiatric Medicine & Surgery Service Providers | Podiatrist | 207P00000X | J1957 | TX | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 0815318-01 | 05 | TX | MEDICAID | 00A27W | 01 | TX | PTAN | OTHER |