Basic Information
Provider Information | |||||||||
NPI: | 1306325618 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | TMC PROVIDER GROUP, PLLC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | TEXAS MEDCLINIC | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 13722 EMBASSY ROW | ||||||||
Address2: |   | ||||||||
City: | SAN ANTONIO | ||||||||
State: | TX | ||||||||
PostalCode: | 782162000 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2103495577 | ||||||||
FaxNumber: | 2104912868 | ||||||||
Practice Location | |||||||||
Address1: | 426 SINGING OAKS | ||||||||
Address2: |   | ||||||||
City: | SPRING BRANCH | ||||||||
State: | TX | ||||||||
PostalCode: | 780706508 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8306325740 | ||||||||
FaxNumber: | 8306325743 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 08/08/2018 | ||||||||
LastUpdateDate: | 08/08/2018 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | RAMOS | ||||||||
AuthorizedOfficialFirstName: | CHANTEL | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | PROFESSIONAL SERVICES SUPERVISOR | ||||||||
AuthorizedOfficialTelephone: | 2103495577 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | Y | ||||||||
ParentOrganizationLBN: | TMC PROVIDER GROUP, PLLC | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QU0200X | F0031 | TX | Y |   | Ambulatory Health Care Facilities | Clinic/Center | Urgent Care |
ID Information
ID | Type | State | Issuer | Description | 1053784660 | 01 | TX | URGENT CARE | OTHER |