Basic Information
| Provider Information | |||||||||
| NPI: | 1952820599 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | TMC PROVIDER GROUP, PLLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | TEXAS MEDCLINIC | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 13722 EMBASSY ROW | ||||||||
| Address2: | |||||||||
| City: | SAN ANTONIO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 782162000 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2103495577 | ||||||||
| FaxNumber: | 2104912868 | ||||||||
| Practice Location | |||||||||
| Address1: | 1922 S. STATE HWY 46 | ||||||||
| Address2: | |||||||||
| City: | NEW BRAUNFELS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 78216 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2103495577 | ||||||||
| FaxNumber: | 2104912868 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/14/2017 | ||||||||
| LastUpdateDate: | 09/14/2017 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | RAMOS | ||||||||
| AuthorizedOfficialFirstName: | CHANTEL | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | PROFESSIONAL SERVICES SUPERVISOR | ||||||||
| AuthorizedOfficialTelephone: | 2103495577 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | TMC PROVIDER GROUP, PLLC | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | F0031 | TX | Y | 193200000X MULTI-SPECIALTY GROUP | Other Service Providers | Specialist |
ID Information
| ID | Type | State | Issuer | Description | 1053784660 | 01 | TX | URGENT CARE | OTHER |