Provider Demographics
NPI:1104086966
Name:FAMILY MEDICAL CLINIC OF MESQUITE, PA
Entity type:Organization
Organization Name:FAMILY MEDICAL CLINIC OF MESQUITE, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JOEL
Authorized Official - Middle Name:D
Authorized Official - Last Name:HOLLIDAY
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:972-279-6595
Mailing Address - Street 1:2540 N GALLOWAY AVE
Mailing Address - Street 2:SUITE 103
Mailing Address - City:MESQUITE
Mailing Address - State:TX
Mailing Address - Zip Code:75150-6306
Mailing Address - Country:US
Mailing Address - Phone:972-279-6595
Mailing Address - Fax:972-613-3737
Practice Address - Street 1:2540 N GALLOWAY AVE
Practice Address - Street 2:SUITE 103
Practice Address - City:MESQUITE
Practice Address - State:TX
Practice Address - Zip Code:75150-6306
Practice Address - Country:US
Practice Address - Phone:972-279-6595
Practice Address - Fax:972-613-3737
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-06-13
Last Update Date:2014-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXD3614207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX201526501Medicaid
TXDP1469OtherMEDICARE RAIL ROAD
TX00Z908Medicare PIN