Provider Demographics
NPI:1629162805
Name:CLEBURNE INTERNAL MEDICINE ASSOCIATES, PA
Entity Type:Organization
Organization Name:CLEBURNE INTERNAL MEDICINE ASSOCIATES, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:BRENT
Authorized Official - Middle Name:HOLMES
Authorized Official - Last Name:WALLACE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:817-641-5221
Mailing Address - Street 1:141 HYDE PARK BLVD
Mailing Address - Street 2:
Mailing Address - City:CLEBURNE
Mailing Address - State:TX
Mailing Address - Zip Code:76033-4561
Mailing Address - Country:US
Mailing Address - Phone:817-641-5221
Mailing Address - Fax:817-517-5241
Practice Address - Street 1:141 HYDE PARK BLVD
Practice Address - Street 2:
Practice Address - City:CLEBURNE
Practice Address - State:TX
Practice Address - Zip Code:76033-4561
Practice Address - Country:US
Practice Address - Phone:817-641-5221
Practice Address - Fax:817-517-5241
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-03
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX00837NOtherBCBS GROUP NUMBER
TX00837NOtherBCBS GROUP NUMBER
TX00837NMedicare ID - Type UnspecifiedGROUP NUMBER