Basic Information
| Provider Information | |||||||||
| NPI: | 1619078920 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CENTRAL TEXAS ORTHOPEDIC SURGERY,P.A. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2510 CROCKETT DR | ||||||||
| Address2: | SUITE A | ||||||||
| City: | BROWNWOOD | ||||||||
| State: | TX | ||||||||
| PostalCode: | 768015928 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3256435513 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2510 CROCKETT DR | ||||||||
| Address2: | SUITE A | ||||||||
| City: | BROWNWOOD | ||||||||
| State: | TX | ||||||||
| PostalCode: | 768015928 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3256435513 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 09/26/2006 | ||||||||
| LastUpdateDate: | 07/22/2008 | ||||||||
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| AuthorizedOfficialLastName: | CLARK | ||||||||
| AuthorizedOfficialFirstName: | CRESCENT | ||||||||
| AuthorizedOfficialMiddleName: | L | ||||||||
| AuthorizedOfficialTitleorPosition: | MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 3256435513 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207X00000X | J6662 | TX | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Orthopaedic Surgery |
ID Information
| ID | Type | State | Issuer | Description | 0040AV | 01 | TX | BLUE CROSS BLUE SHIELD TX | OTHER | 119756 | 01 | TX | SUPERIOR HEALTH PLAN | OTHER | 127632105 | 05 | TX | MEDICAID | 181622100 | 01 | TX | DEPT OF LABOR | OTHER | 8X1180 | 01 | TX | BLUE CROSS BLUE SHIELD TX | OTHER |