Provider Demographics
NPI:1376513911
Name:CORPUS CHRISTI FAMILY MEDICINE CENTER PA
Entity Type:Organization
Organization Name:CORPUS CHRISTI FAMILY MEDICINE CENTER PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JONATHAN
Authorized Official - Middle Name:E
Authorized Official - Last Name:MARTIN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:361-808-7200
Mailing Address - Street 1:601 TEXAN TRL
Mailing Address - Street 2:SUITE 200
Mailing Address - City:CORPUS CHRISTI
Mailing Address - State:TX
Mailing Address - Zip Code:78411-2547
Mailing Address - Country:US
Mailing Address - Phone:361-808-7200
Mailing Address - Fax:361-225-0020
Practice Address - Street 1:601 TEXAN TRL
Practice Address - Street 2:SUITE 200
Practice Address - City:CORPUS CHRISTI
Practice Address - State:TX
Practice Address - Zip Code:78411-2547
Practice Address - Country:US
Practice Address - Phone:361-808-7200
Practice Address - Fax:361-225-0020
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-01-25
Last Update Date:2012-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX156123501Medicaid
TX156123501Medicaid