Provider Demographics
NPI:1265634083
Name:EXECUTIVE MEDICAL CLINIC
Entity Type:Organization
Organization Name:EXECUTIVE MEDICAL CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:C.J.
Authorized Official - Middle Name:
Authorized Official - Last Name:BURGIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:210-767-9042
Mailing Address - Street 1:2601 HOSPITAL BLVD
Mailing Address - Street 2:STE 117
Mailing Address - City:CORPUS CHRISTI
Mailing Address - State:TX
Mailing Address - Zip Code:78405-1815
Mailing Address - Country:US
Mailing Address - Phone:361-884-8209
Mailing Address - Fax:361-882-6649
Practice Address - Street 1:2601 HOSPITAL BLVD
Practice Address - Street 2:STE 117
Practice Address - City:CORPUS CHRISTI
Practice Address - State:TX
Practice Address - Zip Code:78405-1815
Practice Address - Country:US
Practice Address - Phone:361-884-8209
Practice Address - Fax:361-882-6649
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-04
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX=========OtherEIN
TX00R21TMedicare ID - Type Unspecified