Provider Demographics
NPI:1104928431
Name:MIDLOTHIAN FAMILY MEDICINE CLINIC
Entity type:Organization
Organization Name:MIDLOTHIAN FAMILY MEDICINE CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:BOB
Authorized Official - Middle Name:KELLY
Authorized Official - Last Name:FELTY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:972-723-1185
Mailing Address - Street 1:200 SILKEN CROSSING
Mailing Address - Street 2:SUITE 201
Mailing Address - City:MIDLOTHIAN
Mailing Address - State:TX
Mailing Address - Zip Code:76065
Mailing Address - Country:US
Mailing Address - Phone:972-723-1185
Mailing Address - Fax:972-723-4003
Practice Address - Street 1:200 SILKEN XING
Practice Address - Street 2:SUITE 201
Practice Address - City:MIDLOTHIAN
Practice Address - State:TX
Practice Address - Zip Code:76065-5586
Practice Address - Country:US
Practice Address - Phone:972-723-1185
Practice Address - Fax:972-723-4003
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-05
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXH6210207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty