Basic Information
| Provider Information | |||||||||
| NPI: | 1720046444 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MEDICAL CENTER MEDICAL GROUP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1000 PINE ST | ||||||||
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| City: | TEXARKANA | ||||||||
| State: | TX | ||||||||
| PostalCode: | 755015100 | ||||||||
| CountryCode: | US | ||||||||
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| Address1: | 1000 PINE ST | ||||||||
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| City: | TEXARKANA | ||||||||
| State: | TX | ||||||||
| PostalCode: | 755015100 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9037987365 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/02/2006 | ||||||||
| LastUpdateDate: | 07/21/2022 | ||||||||
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| AuthorizedOfficialLastName: | POTTER | ||||||||
| AuthorizedOfficialFirstName: | MIKE | ||||||||
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| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 9037987365 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207L00000X | TX | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Anesthesiology |
ID Information
| ID | Type | State | Issuer | Description | 163118602 | 05 | TX | MEDICAID |