Provider Demographics
NPI:1043901788
Name:PRIMARY CARE OF EAGLE PASS PLLC
Entity Type:Organization
Organization Name:PRIMARY CARE OF EAGLE PASS PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SOLE MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:W
Authorized Official - Last Name:CHISUM
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:830-213-8186
Mailing Address - Street 1:1975 N VETERANS BLVD STE 9
Mailing Address - Street 2:
Mailing Address - City:EAGLE PASS
Mailing Address - State:TX
Mailing Address - Zip Code:78852-4456
Mailing Address - Country:US
Mailing Address - Phone:830-213-8186
Mailing Address - Fax:830-213-8157
Practice Address - Street 1:1975 N VETERANS BLVD STE 9
Practice Address - Street 2:
Practice Address - City:EAGLE PASS
Practice Address - State:TX
Practice Address - Zip Code:78852-4456
Practice Address - Country:US
Practice Address - Phone:830-213-8186
Practice Address - Fax:830-213-8157
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-05-15
Last Update Date:2023-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty