Provider Demographics
NPI:1841322013
Name:SMITHSON VALLEY FAMILY MEDICINE, LLP
Entity type:Organization
Organization Name:SMITHSON VALLEY FAMILY MEDICINE, LLP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MATTHEW
Authorized Official - Middle Name:W
Authorized Official - Last Name:NICOLA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:830-885-5541
Mailing Address - Street 1:6098 FM 311
Mailing Address - Street 2:SMITHSON VALLEY FAMILY MEDICINE
Mailing Address - City:SPRING BRANCH
Mailing Address - State:TX
Mailing Address - Zip Code:78070-7253
Mailing Address - Country:US
Mailing Address - Phone:830-885-5541
Mailing Address - Fax:830-885-5542
Practice Address - Street 1:6098 FM 311
Practice Address - Street 2:SMITHSON VALLEY FAMILY MEDICINE
Practice Address - City:SPRING BRANCH
Practice Address - State:TX
Practice Address - Zip Code:78070-7253
Practice Address - Country:US
Practice Address - Phone:830-885-5541
Practice Address - Fax:830-885-5542
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-12
Last Update Date:2008-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXK5049207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX178787102Medicaid
TX169864902Medicaid
TXH80252Medicare UPIN
TXI48696Medicare UPIN
TX8F2239Medicare ID - Type UnspecifiedID#
TX178787102Medicaid
TX169864902Medicaid