Basic Information
Provider Information | |||||||||
NPI: | 1689651440 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | MCLENNAN COUNTY MEDICAL EDUCATION AND RESEARCH FOUNDATION | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | FAMILY HEALTH CENTER | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1600 PROVIDENCE DR | ||||||||
Address2: |   | ||||||||
City: | WACO | ||||||||
State: | TX | ||||||||
PostalCode: | 767072261 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2543134200 | ||||||||
FaxNumber: | 2543134326 | ||||||||
Practice Location | |||||||||
Address1: | 1600 PROVIDENCE DR | ||||||||
Address2: |   | ||||||||
City: | WACO | ||||||||
State: | TX | ||||||||
PostalCode: | 767072261 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2543134200 | ||||||||
FaxNumber: | 2543134531 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 12/22/2005 | ||||||||
LastUpdateDate: | 07/12/2016 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | BALLEW | ||||||||
AuthorizedOfficialFirstName: | ANNETTE | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | CFO | ||||||||
AuthorizedOfficialTelephone: | 2543134282 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | MRS. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | CPA | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X |   |   | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |   |
ID Information
ID | Type | State | Issuer | Description | 121447001 | 05 | TX |   | MEDICAID | 121447002 | 05 | TX |   | MEDICAID | 121447003 | 05 | TX |   | MEDICAID |