Basic Information
| Provider Information | |||||||||
| NPI: | 1144485756 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | WEST TEXAS MEDICAL ASSOCIATES | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3605 EXECUTIVE DR | ||||||||
| Address2: | |||||||||
| City: | SAN ANGELO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 769046884 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3259499555 | ||||||||
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| Address1: | 3605 EXECUTIVE DR | ||||||||
| Address2: | |||||||||
| City: | SAN ANGELO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 76904 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3259499555 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/23/2008 | ||||||||
| LastUpdateDate: | 12/05/2018 | ||||||||
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| AuthorizedOfficialLastName: | MCMAHON | ||||||||
| AuthorizedOfficialFirstName: | TOMMY | ||||||||
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| AuthorizedOfficialTitleorPosition: | ADMINISTRATOR | ||||||||
| AuthorizedOfficialTelephone: | 3259499555 | ||||||||
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| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | WEST TEXAS MEDICAL ASSOCIATES | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine | 207R00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | 208000000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 135031606 | 05 | TX | MEDICAID |