Provider Demographics
NPI:1477646271
Name:WILLIAM NISIMBLAT MDPA
Entity Type:Organization
Organization Name:WILLIAM NISIMBLAT MDPA
Other - Org Name:ALICE PEDIATRIC CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:
Authorized Official - Last Name:NISIMBLAT
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:361-664-5291
Mailing Address - Street 1:PO BOX 289
Mailing Address - Street 2:
Mailing Address - City:ALICE
Mailing Address - State:TX
Mailing Address - Zip Code:78333-4705
Mailing Address - Country:US
Mailing Address - Phone:361-664-9353
Mailing Address - Fax:
Practice Address - Street 1:305 E THIRD ST
Practice Address - Street 2:
Practice Address - City:ALICE
Practice Address - State:TX
Practice Address - Zip Code:78332-4705
Practice Address - Country:US
Practice Address - Phone:361-664-5291
Practice Address - Fax:361-668-1630
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-02
Last Update Date:2011-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
No261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural HealthGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX119654501Medicaid
TX119654502Medicaid
TX00T57WMedicare ID - Type Unspecified