Provider Demographics
NPI:1053464982
Name:FREDERICKSBURG FAMILY CLINIC PA
Entity Type:Organization
Organization Name:FREDERICKSBURG FAMILY CLINIC PA
Other - Org Name:CORNERSTONE CLINIC AT COMFORT
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:CATHY
Authorized Official - Middle Name:
Authorized Official - Last Name:DONAHY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:830-997-0330
Mailing Address - Street 1:514 W WINDCREST ST
Mailing Address - Street 2:
Mailing Address - City:FREDERICKSBURG
Mailing Address - State:TX
Mailing Address - Zip Code:78624-4633
Mailing Address - Country:US
Mailing Address - Phone:830-997-0330
Mailing Address - Fax:
Practice Address - Street 1:815 FRONT ST
Practice Address - Street 2:
Practice Address - City:COMFORT
Practice Address - State:TX
Practice Address - Zip Code:78013
Practice Address - Country:US
Practice Address - Phone:830-995-5633
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-22
Last Update Date:2022-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX0009QHOtherBCBSTX
TX189877703Medicaid
TXDG7779OtherMEDICARE RAILROAD
TX189877702OtherMEDICAID EPSDT
TX189877703Medicaid