Provider Demographics
NPI:1053672535
Name:DISCOVERY MEDICAL NETWORK MATAGORDA LLC
Entity Type:Organization
Organization Name:DISCOVERY MEDICAL NETWORK MATAGORDA LLC
Other - Org Name:MATAGORDA MEDICAL GROUP
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:DERRELL
Authorized Official - Middle Name:M
Authorized Official - Last Name:HAVINS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:806-791-1591
Mailing Address - Street 1:2950 50TH ST
Mailing Address - Street 2:
Mailing Address - City:LUBBOCK
Mailing Address - State:TX
Mailing Address - Zip Code:79413-4326
Mailing Address - Country:US
Mailing Address - Phone:806-791-1591
Mailing Address - Fax:
Practice Address - Street 1:600 HOSPITAL CIR
Practice Address - Street 2:
Practice Address - City:BAY CITY
Practice Address - State:TX
Practice Address - Zip Code:77414-4771
Practice Address - Country:US
Practice Address - Phone:979-245-0001
Practice Address - Fax:979-244-8103
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:DISCOVERY MEDICAL NETWORK INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2012-05-31
Last Update Date:2019-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
No208800000XAllopathic & Osteopathic PhysiciansUrologyGroup - Multi-Specialty
No261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural HealthGroup - Multi-Specialty