Provider Demographics
NPI:1619078920
Name:CENTRAL TEXAS ORTHOPEDIC SURGERY,P.A.
Entity Type:Organization
Organization Name:CENTRAL TEXAS ORTHOPEDIC SURGERY,P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:CRESCENT
Authorized Official - Middle Name:L
Authorized Official - Last Name:CLARK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:325-643-5513
Mailing Address - Street 1:2510 CROCKETT DR
Mailing Address - Street 2:SUITE A
Mailing Address - City:BROWNWOOD
Mailing Address - State:TX
Mailing Address - Zip Code:76801-5928
Mailing Address - Country:US
Mailing Address - Phone:325-643-5513
Mailing Address - Fax:
Practice Address - Street 1:2510 CROCKETT DR
Practice Address - Street 2:SUITE A
Practice Address - City:BROWNWOOD
Practice Address - State:TX
Practice Address - Zip Code:76801-5928
Practice Address - Country:US
Practice Address - Phone:325-643-5513
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-26
Last Update Date:2008-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXJ6662207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX0040AVOtherBLUE CROSS BLUE SHIELD TX
TX119756OtherSUPERIOR HEALTH PLAN
TX127632105Medicaid
TX181622100OtherDEPT OF LABOR
TX8X1180OtherBLUE CROSS BLUE SHIELD TX
TX181622100OtherDEPT OF LABOR
TX200040090Medicare PIN
TX119756OtherSUPERIOR HEALTH PLAN
TX8X1180OtherBLUE CROSS BLUE SHIELD TX