Provider Demographics
NPI:1073820254
Name:EICHELBERGER MEDICAL PRACTICE, P.A.
Entity Type:Organization
Organization Name:EICHELBERGER MEDICAL PRACTICE, P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:PHILIP
Authorized Official - Middle Name:THEODRIC
Authorized Official - Last Name:EICHELBERGER
Authorized Official - Suffix:JR
Authorized Official - Credentials:MD
Authorized Official - Phone:281-427-8502
Mailing Address - Street 1:1610 JAMES BOWIE DRIVE
Mailing Address - Street 2:SUITE A103
Mailing Address - City:BAYTOWN
Mailing Address - State:TX
Mailing Address - Zip Code:77520-3346
Mailing Address - Country:US
Mailing Address - Phone:281-427-8502
Mailing Address - Fax:281-420-5575
Practice Address - Street 1:1610 JAMES BOWIE DRIVE
Practice Address - Street 2:SUITE A103
Practice Address - City:BAYTOWN
Practice Address - State:TX
Practice Address - Zip Code:77520-3346
Practice Address - Country:US
Practice Address - Phone:281-427-8502
Practice Address - Fax:281-420-5575
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-09-09
Last Update Date:2010-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXC6308208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX122199604Medicaid
TX122199604Medicaid