Provider Demographics
NPI:1619902848
Name:FMC MEDICAL FOUNDATION, INC
Entity Type:Organization
Organization Name:FMC MEDICAL FOUNDATION, INC
Other - Org Name:FAMILY MEDICINE CENTER CANYON
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:CREDENTIALING SPECIALIST
Authorized Official - Prefix:
Authorized Official - First Name:STEFANIE
Authorized Official - Middle Name:
Authorized Official - Last Name:FEEMSTER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:806-358-9400
Mailing Address - Street 1:911 23RD STREET
Mailing Address - Street 2:
Mailing Address - City:CANYON
Mailing Address - State:TX
Mailing Address - Zip Code:79015-4600
Mailing Address - Country:US
Mailing Address - Phone:806-655-2104
Mailing Address - Fax:806-655-0522
Practice Address - Street 1:911 23RD STREET
Practice Address - Street 2:
Practice Address - City:CANYON
Practice Address - State:TX
Practice Address - Zip Code:79015-4600
Practice Address - Country:US
Practice Address - Phone:806-655-2104
Practice Address - Fax:806-655-0522
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-12
Last Update Date:2020-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Multi-Specialty
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX45D0506538OtherCLIA
TX45D0506538OtherCLIA
TX092485403Medicaid
TX092485404Medicaid
TXR04815OtherBUREAU OF RADIATION CONTR
TX00887NMedicare UPIN
TX00887NMedicare PIN
TXCH4959Medicare ID - Type UnspecifiedMEDICARE RAILROAD