Provider Demographics
NPI:1962424846
Name:PILOT POINT MEDICAL CLINIC, P.A.
Entity type:Organization
Organization Name:PILOT POINT MEDICAL CLINIC, P.A.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:KENNETH
Authorized Official - Middle Name:WAYNE
Authorized Official - Last Name:BERESFORD
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:940-686-2254
Mailing Address - Street 1:PO BOX 1117
Mailing Address - Street 2:1246 HWY 377 SOUTH SUITE 200
Mailing Address - City:PILOT POINT
Mailing Address - State:TX
Mailing Address - Zip Code:76258-1117
Mailing Address - Country:US
Mailing Address - Phone:940-686-2254
Mailing Address - Fax:940-686-2830
Practice Address - Street 1:1246 S HIGHWAY 377
Practice Address - Street 2:
Practice Address - City:PILOT POINT
Practice Address - State:TX
Practice Address - Zip Code:76258-4375
Practice Address - Country:US
Practice Address - Phone:940-686-2254
Practice Address - Fax:940-686-2830
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-23
Last Update Date:2012-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXK9226261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX045386202Medicaid
TX0A3440OtherMEDICARE GROUP PTAN
TX8F20689OtherMEDICARE INDIV PTAN INDVID NPI
0A3440OtherMEDICARE INDIVID PTAN FOR GRP NPI
TX8F20689OtherMEDICARE INDIV PTAN INDVID NPI
TX045386202Medicaid