Provider Demographics
NPI:1992818181
Name:THE PHYSICIANS CLINIC PA
Entity type:Organization
Organization Name:THE PHYSICIANS CLINIC PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:ANDREW
Authorized Official - Middle Name:E
Authorized Official - Last Name:BENTLEY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:903-245-9647
Mailing Address - Street 1:13082 COUNTY ROAD 2320
Mailing Address - Street 2:
Mailing Address - City:TYLER
Mailing Address - State:TX
Mailing Address - Zip Code:75707-5914
Mailing Address - Country:US
Mailing Address - Phone:903-245-9647
Mailing Address - Fax:
Practice Address - Street 1:13082 COUNTY ROAD 2320
Practice Address - Street 2:
Practice Address - City:TYLER
Practice Address - State:TX
Practice Address - Zip Code:75707-5914
Practice Address - Country:US
Practice Address - Phone:903-245-9647
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-15
Last Update Date:2013-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX159935901Medicaid
TX0056JFOtherBLUE CROSS BLUE SHIELD
TX159935901Medicaid