Provider Demographics
NPI:1427035161
Name:ONE MEDIC LANE PHYSICIANS PLLC
Entity Type:Organization
Organization Name:ONE MEDIC LANE PHYSICIANS PLLC
Other - Org Name:MEDIC LANE PHYSICIANS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:BILLING MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:TINA
Authorized Official - Middle Name:
Authorized Official - Last Name:BAKER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:281-331-0082
Mailing Address - Street 1:PO BOX 1968
Mailing Address - Street 2:
Mailing Address - City:ALVIN
Mailing Address - State:TX
Mailing Address - Zip Code:77512-1968
Mailing Address - Country:US
Mailing Address - Phone:281-331-0082
Mailing Address - Fax:281-331-4802
Practice Address - Street 1:400 MEDIC LN STE C
Practice Address - Street 2:
Practice Address - City:ALVIN
Practice Address - State:TX
Practice Address - Zip Code:77511-5567
Practice Address - Country:US
Practice Address - Phone:281-331-0082
Practice Address - Fax:281-331-2624
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-12-23
Last Update Date:2022-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX00693KMedicare PIN