Provider Demographics
NPI:1407070758
Name:MINERAL WELLS WOMEN'S PAVILION, P.A.
Entity Type:Organization
Organization Name:MINERAL WELLS WOMEN'S PAVILION, P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:TIM
Authorized Official - Middle Name:
Authorized Official - Last Name:TARKENTON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:940-328-1261
Mailing Address - Street 1:220 SW 26TH AVENUE
Mailing Address - Street 2:
Mailing Address - City:MINERAL WELLS
Mailing Address - State:TX
Mailing Address - Zip Code:76067
Mailing Address - Country:US
Mailing Address - Phone:940-328-1261
Mailing Address - Fax:
Practice Address - Street 1:220 SW 26TH AVENUE
Practice Address - Street 2:
Practice Address - City:MINERAL WELLS
Practice Address - State:TX
Practice Address - Zip Code:76067
Practice Address - Country:US
Practice Address - Phone:940-328-1261
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-11
Last Update Date:2008-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXH2824207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX123030201Medicaid
TX10020986OtherAMERIGROUP
TX00786KMedicare PIN
TX10020986OtherAMERIGROUP