Provider Demographics
NPI:1447602214
Name:WAXAHACHIE MEDICAL PLLC
Entity Type:Organization
Organization Name:WAXAHACHIE MEDICAL PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:BRENT
Authorized Official - Middle Name:W
Authorized Official - Last Name:GALLOWAY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:214-619-5664
Mailing Address - Street 1:401 N HIGHWAY 77
Mailing Address - Street 2:SUITE # 1
Mailing Address - City:WAXAHACHIE
Mailing Address - State:TX
Mailing Address - Zip Code:75165-1130
Mailing Address - Country:US
Mailing Address - Phone:214-619-5664
Mailing Address - Fax:469-930-4446
Practice Address - Street 1:401 N HIGHWAY 77
Practice Address - Street 2:SUITE # 1
Practice Address - City:WAXAHACHIE
Practice Address - State:TX
Practice Address - Zip Code:75165-1130
Practice Address - Country:US
Practice Address - Phone:214-619-5664
Practice Address - Fax:469-930-4446
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-07-05
Last Update Date:2016-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXN4420207Q00000X, 261QM2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical SpecialtyGroup - Multi-Specialty