Provider Demographics
NPI:1124050836
Name:CORRIDOR PRIMARY CARE, PA
Entity type:Organization
Organization Name:CORRIDOR PRIMARY CARE, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:MICHELLE
Authorized Official - Middle Name:M
Authorized Official - Last Name:BLUDWORTH
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:512-392-1700
Mailing Address - Street 1:1320 WONDER WORLD DR STE 101
Mailing Address - Street 2:
Mailing Address - City:SAN MARCOS
Mailing Address - State:TX
Mailing Address - Zip Code:78666-7558
Mailing Address - Country:US
Mailing Address - Phone:512-392-1700
Mailing Address - Fax:512-396-8743
Practice Address - Street 1:1320 WONDER WORLD DR STE 101
Practice Address - Street 2:
Practice Address - City:SAN MARCOS
Practice Address - State:TX
Practice Address - Zip Code:78666-7558
Practice Address - Country:US
Practice Address - Phone:512-392-1700
Practice Address - Fax:512-396-8743
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-06
Last Update Date:2007-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX00T63UMedicare UPIN