Provider Demographics
NPI:1417020959
Name:WACO ORTHOPEDIC CLINIC
Entity Type:Organization
Organization Name:WACO ORTHOPEDIC CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN PARTNER
Authorized Official - Prefix:
Authorized Official - First Name:JON
Authorized Official - Middle Name:MARC
Authorized Official - Last Name:GOODNIGHT
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:254-752-9638
Mailing Address - Street 1:6600 FISH POND RD
Mailing Address - Street 2:SUITE 201
Mailing Address - City:WACO
Mailing Address - State:TX
Mailing Address - Zip Code:76710-2581
Mailing Address - Country:US
Mailing Address - Phone:254-752-9638
Mailing Address - Fax:254-752-2201
Practice Address - Street 1:6600 FISH POND RD
Practice Address - Street 2:SUITE 201
Practice Address - City:WACO
Practice Address - State:TX
Practice Address - Zip Code:76710-2581
Practice Address - Country:US
Practice Address - Phone:254-752-9638
Practice Address - Fax:254-752-2201
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-15
Last Update Date:2008-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX083305501Medicaid
00JH19Medicare ID - Type Unspecified