Provider Demographics
NPI:1225295298
Name:PHYNET, INC
Entity Type:Organization
Organization Name:PHYNET, INC
Other - Org Name:TATUM MEDICAL CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:D
Authorized Official - Last Name:FORD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:903-247-0484
Mailing Address - Street 1:4002 TECHNOLOGY CTR
Mailing Address - Street 2:
Mailing Address - City:LONGVIEW
Mailing Address - State:TX
Mailing Address - Zip Code:75605-2697
Mailing Address - Country:US
Mailing Address - Phone:903-247-0484
Mailing Address - Fax:903-247-0485
Practice Address - Street 1:800 N HILL ST
Practice Address - Street 2:
Practice Address - City:TATUM
Practice Address - State:TX
Practice Address - Zip Code:75691-1740
Practice Address - Country:US
Practice Address - Phone:903-947-6300
Practice Address - Fax:903-947-2408
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PHYNET, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-05-19
Last Update Date:2010-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX159694201Medicaid
TX159694201Medicaid