Provider Demographics
NPI:1164908463
Name:RAYMOND WESTBROOK DO PA
Entity Type:Organization
Organization Name:RAYMOND WESTBROOK DO PA
Other - Org Name:GENESIS INTEGRATED MEDICINE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CREDENTIALING
Authorized Official - Prefix:
Authorized Official - First Name:STACY
Authorized Official - Middle Name:LYLES
Authorized Official - Last Name:HAWKINS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:361-356-3110
Mailing Address - Street 1:2701 MATLOCK RD STE 105
Mailing Address - Street 2:
Mailing Address - City:ARLINGTON
Mailing Address - State:TX
Mailing Address - Zip Code:76015-2529
Mailing Address - Country:US
Mailing Address - Phone:817-786-3040
Mailing Address - Fax:817-786-3041
Practice Address - Street 1:520 E NORTHWEST HWY STE 102
Practice Address - Street 2:
Practice Address - City:GRAPEVINE
Practice Address - State:TX
Practice Address - Zip Code:76051
Practice Address - Country:US
Practice Address - Phone:817-328-1922
Practice Address - Fax:817-328-1933
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:RAYMOND WESTBROOK DO PA
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2018-07-19
Last Update Date:2018-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX045797004Medicaid
TX045797003Medicaid
TX045797005Medicaid