Provider Demographics
NPI:1245212745
Name:WACO PM&R GROUP, PA
Entity Type:Organization
Organization Name:WACO PM&R GROUP, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:E
Authorized Official - Last Name:SCOTT
Authorized Official - Suffix:JR
Authorized Official - Credentials:DO
Authorized Official - Phone:254-753-7200
Mailing Address - Street 1:PO BOX 22052
Mailing Address - Street 2:
Mailing Address - City:WACO
Mailing Address - State:TX
Mailing Address - Zip Code:76702-2052
Mailing Address - Country:US
Mailing Address - Phone:254-753-7200
Mailing Address - Fax:254-753-0388
Practice Address - Street 1:50 HILLCREST MEDICAL BLVD.
Practice Address - Street 2:SUITE 104
Practice Address - City:WACO
Practice Address - State:TX
Practice Address - Zip Code:76712
Practice Address - Country:US
Practice Address - Phone:254-753-7200
Practice Address - Fax:254-753-0388
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-11-18
Last Update Date:2010-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXJ8763208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1136053-04Medicaid
TX250011083OtherMEDICARE RAILROAD
TX1136053-04Medicaid