Provider Demographics
NPI:1104996735
Name:MEDICAL PARKWAY FAMILY PRACTICE,LLP
Entity type:Organization
Organization Name:MEDICAL PARKWAY FAMILY PRACTICE,LLP
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:LISA
Authorized Official - Middle Name:JOHNSON
Authorized Official - Last Name:KIRK
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:254-776-8008
Mailing Address - Street 1:318 RICHLAND WEST CIR
Mailing Address - Street 2:SUITE A
Mailing Address - City:WACO
Mailing Address - State:TX
Mailing Address - Zip Code:76712-7919
Mailing Address - Country:US
Mailing Address - Phone:254-776-8008
Mailing Address - Fax:254-776-6892
Practice Address - Street 1:318 RICHLAND WEST CIR
Practice Address - Street 2:SUITE A
Practice Address - City:WACO
Practice Address - State:TX
Practice Address - Zip Code:76712-7919
Practice Address - Country:US
Practice Address - Phone:254-776-8008
Practice Address - Fax:254-776-6892
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-09
Last Update Date:2009-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX151015803Medicaid
TX00526TMedicare ID - Type UnspecifiedMEDICARE GROUP NUMBER
TX5488400001Medicare NSC