Basic Information
| Provider Information | |||||||||
| NPI: | 1740237148 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ALVORD MEDICAL CLINIC, PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 49 | ||||||||
| Address2: | |||||||||
| City: | ALVORD | ||||||||
| State: | TX | ||||||||
| PostalCode: | 762250049 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9404272858 | ||||||||
| FaxNumber: | 9404272857 | ||||||||
| Practice Location | |||||||||
| Address1: | 115 E BYPASS 287 | ||||||||
| Address2: | STE A | ||||||||
| City: | ALVORD | ||||||||
| State: | TX | ||||||||
| PostalCode: | 762257778 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9404272858 | ||||||||
| FaxNumber: | 9404272857 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/30/2006 | ||||||||
| LastUpdateDate: | 12/01/2016 | ||||||||
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| AuthorizedOfficialLastName: | ALLING | ||||||||
| AuthorizedOfficialFirstName: | JEFFERSON | ||||||||
| AuthorizedOfficialMiddleName: | B | ||||||||
| AuthorizedOfficialTitleorPosition: | MD/OWNER | ||||||||
| AuthorizedOfficialTelephone: | 9406277829 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 453934 | 01 | TX | MEDICARE | OTHER | 175292501 | 05 | TX | MEDICAID | DF4050 | 01 | TX | RAILROAD MEDICARE | OTHER | 111571903 | 05 | TX | MEDICAID |