Provider Demographics
NPI:1063539542
Name:BASTROP COUNTY MEDICAL & ASSOCIATES, PA
Entity type:Organization
Organization Name:BASTROP COUNTY MEDICAL & ASSOCIATES, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:RAJEEV
Authorized Official - Middle Name:
Authorized Official - Last Name:GUPTA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:512-321-9091
Mailing Address - Street 1:489 AGNES ST
Mailing Address - Street 2:STE 100
Mailing Address - City:BASTROP
Mailing Address - State:TX
Mailing Address - Zip Code:78602-2156
Mailing Address - Country:US
Mailing Address - Phone:512-321-9091
Mailing Address - Fax:512-549-3005
Practice Address - Street 1:489 AGNES ST
Practice Address - Street 2:STE 100
Practice Address - City:BASTROP
Practice Address - State:TX
Practice Address - Zip Code:78602-2156
Practice Address - Country:US
Practice Address - Phone:512-321-9091
Practice Address - Fax:512-549-3005
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-22
Last Update Date:2016-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXK0795174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX092494601Medicaid
TX0071DMOtherBCBS
TXDG3304OtherRAILROAD MEDICARE
TX10008423OtherAMERIGROUP
TX10008423OtherAMERIGROUP
TX00853NMedicare PIN