Provider Demographics
NPI:1427177641
Name:INTERNAL MEDICINE ASSOCIATION OF LONGVIEW
Entity type:Organization
Organization Name:INTERNAL MEDICINE ASSOCIATION OF LONGVIEW
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:LAURIE
Authorized Official - Middle Name:L
Authorized Official - Last Name:OVERHULTZ
Authorized Official - Suffix:
Authorized Official - Credentials:CPCS/CPMSM
Authorized Official - Phone:903-753-7291
Mailing Address - Street 1:703 E MARSHALL AVE
Mailing Address - Street 2:SUITE 1001
Mailing Address - City:LONGVIEW
Mailing Address - State:TX
Mailing Address - Zip Code:75601-5500
Mailing Address - Country:US
Mailing Address - Phone:903-753-7291
Mailing Address - Fax:903-315-5000
Practice Address - Street 1:703 E MARSHALL AVE
Practice Address - Street 2:SUITE 1001
Practice Address - City:LONGVIEW
Practice Address - State:TX
Practice Address - Zip Code:75601-5500
Practice Address - Country:US
Practice Address - Phone:903-753-7291
Practice Address - Fax:903-315-5000
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-28
Last Update Date:2009-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX094970303Medicaid
TX094970303Medicaid