Provider Demographics
NPI:1164997763
Name:MG FAMILY MEDICINE, PLLC
Entity Type:Organization
Organization Name:MG FAMILY MEDICINE, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SOLE MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:MINYING
Authorized Official - Middle Name:
Authorized Official - Last Name:GU
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:618-698-9314
Mailing Address - Street 1:205 KETTLEMAN LN N
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78717-2979
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1611 HEADWAY CIR BLDG 2
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78754-5165
Practice Address - Country:US
Practice Address - Phone:512-454-3795
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-10-10
Last Update Date:2021-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX3868218-01Medicaid