Provider Demographics
NPI:1275711657
Name:PICKETT MEDICAL CENTER P.A
Entity Type:Organization
Organization Name:PICKETT MEDICAL CENTER P.A
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JAN
Authorized Official - Middle Name:W
Authorized Official - Last Name:PICKETT
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:972-625-5442
Mailing Address - Street 1:6600 PAIGE RD
Mailing Address - Street 2:SUITE 105
Mailing Address - City:THE COLONY
Mailing Address - State:TX
Mailing Address - Zip Code:75056-4500
Mailing Address - Country:US
Mailing Address - Phone:972-625-5442
Mailing Address - Fax:972-370-2301
Practice Address - Street 1:6600 PAIGE RD
Practice Address - Street 2:SUTIE 105
Practice Address - City:THE COLONY
Practice Address - State:TX
Practice Address - Zip Code:75056-4500
Practice Address - Country:US
Practice Address - Phone:972-625-5442
Practice Address - Fax:972-370-2301
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-07
Last Update Date:2013-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXH2690261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8F0090OtherBCBS
TXC20513Medicare UPIN
TX00D780Medicare PIN