Provider Demographics
NPI:1073665915
Name:FAMILY MEDICINE RURAL HEALTH CLINIC, PA
Entity Type:Organization
Organization Name:FAMILY MEDICINE RURAL HEALTH CLINIC, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:S
Authorized Official - Last Name:LANE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:512-556-3621
Mailing Address - Street 1:207 W AVENUE E
Mailing Address - Street 2:
Mailing Address - City:LAMPASAS
Mailing Address - State:TX
Mailing Address - Zip Code:76550-1820
Mailing Address - Country:US
Mailing Address - Phone:512-556-3621
Mailing Address - Fax:512-556-6594
Practice Address - Street 1:187 PR 4060
Practice Address - Street 2:
Practice Address - City:LAMPASAS
Practice Address - State:TX
Practice Address - Zip Code:76550-4071
Practice Address - Country:US
Practice Address - Phone:512-556-3621
Practice Address - Fax:512-556-6594
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-18
Last Update Date:2017-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXCG2858OtherRAILROAD MEDICARE
TX121186401Medicaid
TX00U72JOtherBLUE CROSS/BLUE SHIELD
TX121186401Medicaid