Provider Demographics
NPI:1376610469
Name:GEORGETOWN MEDICAL CENTER P A
Entity Type:Organization
Organization Name:GEORGETOWN MEDICAL CENTER P A
Other - Org Name:GEORGETOWN MEDICAL CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:
Authorized Official - Last Name:GUZZINO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:512-930-4593
Mailing Address - Street 1:3201 S AUSTIN AVE STE 210
Mailing Address - Street 2:
Mailing Address - City:GEORGETOWN
Mailing Address - State:TX
Mailing Address - Zip Code:78626-7537
Mailing Address - Country:US
Mailing Address - Phone:512-930-4593
Mailing Address - Fax:
Practice Address - Street 1:3201 S AUSTIN AVE STE 210
Practice Address - Street 2:
Practice Address - City:GEORGETOWN
Practice Address - State:TX
Practice Address - Zip Code:78626-7537
Practice Address - Country:US
Practice Address - Phone:512-930-4593
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-30
Last Update Date:2010-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX127132202Medicaid
TX127132201Medicaid
TX127132203Medicaid
TX127132202Medicaid