Provider Demographics
NPI:1306898374
Name:TEXOMA KIDNEY CARE, P.A.
Entity type:Organization
Organization Name:TEXOMA KIDNEY CARE, P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:GLEN
Authorized Official - Middle Name:ROBERT
Authorized Official - Last Name:WILLIE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:903-463-5057
Mailing Address - Street 1:201 MEMORIAL DR
Mailing Address - Street 2:SUITE 201
Mailing Address - City:DENISON
Mailing Address - State:TX
Mailing Address - Zip Code:75020-2026
Mailing Address - Country:US
Mailing Address - Phone:903-463-5057
Mailing Address - Fax:903-463-7661
Practice Address - Street 1:201 MEMORIAL DR
Practice Address - Street 2:SUITE 201
Practice Address - City:DENISON
Practice Address - State:TX
Practice Address - Zip Code:75020-2026
Practice Address - Country:US
Practice Address - Phone:903-463-5057
Practice Address - Fax:903-463-7661
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-17
Last Update Date:2008-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXG0858174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OKDF3764OtherOK RAILROAD MEDICARE
TX0031EEOtherBLUE CROSS/BLUE SHIELD
TX00065TMedicare ID - Type Unspecified
TXCJ6016Medicare PIN