Provider Demographics
NPI:1053504639
Name:CRANE MEDICAL CLINIC PA
Entity Type:Organization
Organization Name:CRANE MEDICAL CLINIC PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINIC MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:JOSE
Authorized Official - Middle Name:
Authorized Official - Last Name:GUMATO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:432-558-2223
Mailing Address - Street 1:103 S GASTON ST
Mailing Address - Street 2:
Mailing Address - City:CRANE
Mailing Address - State:TX
Mailing Address - Zip Code:79731-2019
Mailing Address - Country:US
Mailing Address - Phone:432-558-2223
Mailing Address - Fax:432-558-2208
Practice Address - Street 1:103 S GASTON ST
Practice Address - Street 2:
Practice Address - City:CRANE
Practice Address - State:TX
Practice Address - Zip Code:79731-2019
Practice Address - Country:US
Practice Address - Phone:432-558-2223
Practice Address - Fax:432-558-2208
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-27
Last Update Date:2010-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX180163101Medicaid
TX180163101Medicaid
TX673889Medicare PIN