Provider Demographics
NPI:1497770390
Name:WISE COUNTY MEDICAL & SURGICAL ASSOCIATION
Entity Type:Organization
Organization Name:WISE COUNTY MEDICAL & SURGICAL ASSOCIATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:KALA
Authorized Official - Middle Name:C
Authorized Official - Last Name:WALSH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:940-627-7829
Mailing Address - Street 1:1306 13TH ST
Mailing Address - Street 2:
Mailing Address - City:BRIDGEPORT
Mailing Address - State:TX
Mailing Address - Zip Code:76426-2454
Mailing Address - Country:US
Mailing Address - Phone:940-627-7443
Mailing Address - Fax:940-627-7597
Practice Address - Street 1:1306 13TH ST
Practice Address - Street 2:
Practice Address - City:BRIDGEPORT
Practice Address - State:TX
Practice Address - Zip Code:76426-2454
Practice Address - Country:US
Practice Address - Phone:940-627-7443
Practice Address - Fax:940-627-7597
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-12
Last Update Date:2010-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No2085B0100XAllopathic & Osteopathic PhysiciansRadiologyBody ImagingGroup - Multi-Specialty
No208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX092162901Medicaid
TXCD5800OtherRAILROAD
TXCD5800OtherRAILROAD