Provider Demographics
NPI:1568098937
Name:MEDSUR ONE TELEMEDICINE LLC
Entity Type:Organization
Organization Name:MEDSUR ONE TELEMEDICINE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:KATHLEEN
Authorized Official - Middle Name:
Authorized Official - Last Name:MCCOY
Authorized Official - Suffix:
Authorized Official - Credentials:NURSE PRACTITION
Authorized Official - Phone:512-364-2151
Mailing Address - Street 1:1309 COFFEEN AVENUE STE 1200
Mailing Address - Street 2:
Mailing Address - City:SHERIDAN
Mailing Address - State:WY
Mailing Address - Zip Code:82801
Mailing Address - Country:US
Mailing Address - Phone:307-655-1666
Mailing Address - Fax:512-651-4666
Practice Address - Street 1:110 EISENHOWER COURT (ADMINISTRATIVE OFFICE LOCATION)
Practice Address - Street 2:1309 COFFEEN AVE STE 1200 SHERIDAN WY 82801
Practice Address - City:GEORGETOWN
Practice Address - State:TX
Practice Address - Zip Code:78633
Practice Address - Country:US
Practice Address - Phone:307-655-1666
Practice Address - Fax:512-651-4666
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-03-18
Last Update Date:2020-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty
No363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult HealthGroup - Multi-Specialty
No363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontologyGroup - Multi-Specialty