Basic Information
| Provider Information | |||||||||
| NPI: | 1093868556 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | SPUR MEDICAL CORPORATION | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | SPUR CLINIC | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 907 E. HILL ST | ||||||||
| Address2: | |||||||||
| City: | SPUR | ||||||||
| State: | TX | ||||||||
| PostalCode: | 793702532 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8062713306 | ||||||||
| FaxNumber: | 8062714256 | ||||||||
| Practice Location | |||||||||
| Address1: | 907 E HILL ST | ||||||||
| Address2: | |||||||||
| City: | SPUR | ||||||||
| State: | TX | ||||||||
| PostalCode: | 793702532 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8062713306 | ||||||||
| FaxNumber: | 8062714256 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/19/2007 | ||||||||
| LastUpdateDate: | 01/30/2009 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | WHITE | ||||||||
| AuthorizedOfficialFirstName: | GLENDA | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | ADMINISTRATOR | ||||||||
| AuthorizedOfficialTelephone: | 8062713306 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | F3709 | TX | N | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine | 261QR1300X | TX | Y | Ambulatory Health Care Facilities | Clinic/Center | Rural Health |
ID Information
| ID | Type | State | Issuer | Description | 063674801 | 05 | TX | MEDICAID | 079808401 | 05 | TX | MEDICAID | 100106106 | 01 | TX | FIRSTCARE PROVIDER NUMBER | OTHER | 1275617177 | 01 | TX | STEVE B. ALLEY, M.D. NPI | OTHER | 1285787762 | 01 | TX | JENNIFER WARREN, NPI# | OTHER | 137930707 | 05 | TX | MEDICAID | 0636748-02 | 05 | TX | MEDICAID |