Provider Demographics
NPI:1114199353
Name:FAMILY CARE CLINIC
Entity Type:Organization
Organization Name:FAMILY CARE CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SUPERVISOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:RAFAT
Authorized Official - Middle Name:
Authorized Official - Last Name:TAJWAR
Authorized Official - Suffix:
Authorized Official - Credentials:BILLING
Authorized Official - Phone:432-689-6818
Mailing Address - Street 1:PO BOX 9753
Mailing Address - Street 2:
Mailing Address - City:MIDLAND
Mailing Address - State:TX
Mailing Address - Zip Code:79708-9753
Mailing Address - Country:US
Mailing Address - Phone:432-689-6818
Mailing Address - Fax:432-699-0817
Practice Address - Street 1:4506 BRIARWOOD AVE
Practice Address - Street 2:
Practice Address - City:MIDLAND
Practice Address - State:TX
Practice Address - Zip Code:79707-2642
Practice Address - Country:US
Practice Address - Phone:432-689-6818
Practice Address - Fax:432-689-6818
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-27
Last Update Date:2008-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX0022DDOtherBLUE CROSS BLUE SHIELD
TX5627454OtherAETNA