Provider Demographics
NPI:1346429032
Name:FAMILY PRACTICE AND OSTEOPATHIC MEDICINE CLINIC
Entity Type:Organization
Organization Name:FAMILY PRACTICE AND OSTEOPATHIC MEDICINE CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DR.
Authorized Official - Prefix:DR
Authorized Official - First Name:FARID
Authorized Official - Middle Name:FRED
Authorized Official - Last Name:TAIE
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:972-398-1665
Mailing Address - Street 1:1409 SHILOH RD
Mailing Address - Street 2:SUITE 150
Mailing Address - City:PLANO
Mailing Address - State:TX
Mailing Address - Zip Code:75074-4332
Mailing Address - Country:US
Mailing Address - Phone:972-398-1665
Mailing Address - Fax:972-398-1677
Practice Address - Street 1:1409 SHILOH RD
Practice Address - Street 2:SUITE 150
Practice Address - City:PLANO
Practice Address - State:TX
Practice Address - Zip Code:75074-4332
Practice Address - Country:US
Practice Address - Phone:972-398-1665
Practice Address - Fax:972-398-1677
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-30
Last Update Date:2007-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXK4813207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX0087MUOtherBLUE CROSS AND BLUE SHIEL
TX0087MUOtherBLUE CROSS AND BLUE SHIEL
TX00478ZMedicare PIN