Basic Information
Provider Information | |||||||||
NPI: | 1992786370 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | COLLOM AND CARNEY CLINIC ASSOCIATION | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | COLLOM AND CARNEY CLINIC ALLERGY & IMMUNOLOGY | ||||||||
OtherOrganizationType: | 5 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 5002 COWHORN CREEK RD | ||||||||
Address2: |   | ||||||||
City: | TEXARKANA | ||||||||
State: | TX | ||||||||
PostalCode: | 755039766 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9036143000 | ||||||||
FaxNumber: | 9036143525 | ||||||||
Practice Location | |||||||||
Address1: | 5002 COWHORN CREEK RD | ||||||||
Address2: |   | ||||||||
City: | TEXARKANA | ||||||||
State: | TX | ||||||||
PostalCode: | 755039766 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9036143000 | ||||||||
FaxNumber: | 9036143525 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 11/11/2005 | ||||||||
LastUpdateDate: | 07/21/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | DWIGHT | ||||||||
AuthorizedOfficialFirstName: | MARY | ||||||||
AuthorizedOfficialMiddleName: | E | ||||||||
AuthorizedOfficialTitleorPosition: | CHIEF OPERATING OFFICER | ||||||||
AuthorizedOfficialTelephone: | 9036143282 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | Y | ||||||||
ParentOrganizationLBN: | COLLOM AND CARNEY CLINIC | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | CCS-P, MHA, CMPE | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207K00000X |   | TX | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Allergy & Immunology |   |
ID Information
ID | Type | State | Issuer | Description | 081264602 | 05 | TX |   | MEDICAID | CU0435 | 01 |   | RAILROAD MEDICARE | OTHER |