Provider Demographics
NPI:1437289956
Name:MEDICAL HOME PARTNERS, PA
Entity Type:Organization
Organization Name:MEDICAL HOME PARTNERS, PA
Other - Org Name:LA VERNIA LIGHTHOUSE HEALTCARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:SUSAN
Authorized Official - Middle Name:A
Authorized Official - Last Name:CROCKETT
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:830-253-8116
Mailing Address - Street 1:PO BOX 190
Mailing Address - Street 2:
Mailing Address - City:LA VERNIA
Mailing Address - State:TX
Mailing Address - Zip Code:78121-0190
Mailing Address - Country:US
Mailing Address - Phone:830-253-8116
Mailing Address - Fax:830-253-8313
Practice Address - Street 1:14114 US HIGHWAY 87 W
Practice Address - Street 2:
Practice Address - City:LA VERNIA
Practice Address - State:TX
Practice Address - Zip Code:78121-5881
Practice Address - Country:US
Practice Address - Phone:830-253-8116
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-06
Last Update Date:2007-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXJ7770207Q00000X, 207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
No207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX00455YMedicare ID - Type Unspecified