Provider Demographics
NPI:1336121490
Name:MONTANA MEDICAL CLINIC-MANUEL HERNANDEZ,M.D.
Entity Type:Organization
Organization Name:MONTANA MEDICAL CLINIC-MANUEL HERNANDEZ,M.D.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:NUEROPHYCHIATRY - GENERAL PRACTICE
Authorized Official - Prefix:DR
Authorized Official - First Name:MANUEL
Authorized Official - Middle Name:
Authorized Official - Last Name:HERNANDEZ
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:915-533-3353
Mailing Address - Street 1:2415 MONTANA AVE
Mailing Address - Street 2:
Mailing Address - City:EL PASO
Mailing Address - State:TX
Mailing Address - Zip Code:79903-3605
Mailing Address - Country:US
Mailing Address - Phone:915-533-3353
Mailing Address - Fax:915-544-4353
Practice Address - Street 1:2415 MONTANA AVE
Practice Address - Street 2:
Practice Address - City:EL PASO
Practice Address - State:TX
Practice Address - Zip Code:79903-3605
Practice Address - Country:US
Practice Address - Phone:915-533-3353
Practice Address - Fax:915-544-4353
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-11-15
Last Update Date:2007-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXC5088305R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305R00000XManaged Care OrganizationsPreferred Provider Organization
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX008646Medicare ID - Type UnspecifiedNEUROPHYCHIATRY - M.D.