Provider Demographics
NPI:1538412895
Name:COVENANT MEDICAL GROUP
Entity type:Organization
Organization Name:COVENANT MEDICAL GROUP
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:COO/VP
Authorized Official - Prefix:
Authorized Official - First Name:KRISTEN
Authorized Official - Middle Name:
Authorized Official - Last Name:KOTHMANN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:806-725-7800
Mailing Address - Street 1:2215 NASHVILLE AVE
Mailing Address - Street 2:
Mailing Address - City:LUBBOCK
Mailing Address - State:TX
Mailing Address - Zip Code:79410-1105
Mailing Address - Country:US
Mailing Address - Phone:806-725-5844
Mailing Address - Fax:806-723-6532
Practice Address - Street 1:409 8TH ST
Practice Address - Street 2:
Practice Address - City:ABERNATHY
Practice Address - State:TX
Practice Address - Zip Code:79311-3416
Practice Address - Country:US
Practice Address - Phone:806-298-5884
Practice Address - Fax:806-298-5889
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-10-23
Last Update Date:2020-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX673910OtherMEDICARE
TX328182601Medicaid