Provider Demographics
NPI:1447232814
Name:COLLOM & CARNEY CLINIC ASSOCIATION
Entity Type:Organization
Organization Name:COLLOM & CARNEY CLINIC ASSOCIATION
Other - Org Name:COLLOM AND CARNEY CLINIC RADIOLOGY
Other - Org Type:Other Name
Authorized Official - Title/Position:CHIEF OPERATING OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:MARY
Authorized Official - Middle Name:E
Authorized Official - Last Name:DWIGHT
Authorized Official - Suffix:
Authorized Official - Credentials:CCS-P, MHA, CMPE
Authorized Official - Phone:903-614-3282
Mailing Address - Street 1:5002 COWHORN CREEK RD
Mailing Address - Street 2:
Mailing Address - City:TEXARKANA
Mailing Address - State:TX
Mailing Address - Zip Code:75503-9766
Mailing Address - Country:US
Mailing Address - Phone:903-614-3000
Mailing Address - Fax:903-614-3525
Practice Address - Street 1:5002 COWHORN CREEK RD
Practice Address - Street 2:
Practice Address - City:TEXARKANA
Practice Address - State:TX
Practice Address - Zip Code:75503-9766
Practice Address - Country:US
Practice Address - Phone:903-614-3000
Practice Address - Fax:903-614-3525
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:COLLOM & CARNEY CLINIC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2005-11-18
Last Update Date:2023-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX261QR0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0200XAmbulatory Health Care FacilitiesClinic/CenterRadiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXCU0435OtherRAILROAD MEDICARE
TX082238901Medicaid