Provider Demographics
NPI:1639304033
Name:HEART OF TEXAS INTERNAL MEDICINE ASSOCIATES, PA
Entity Type:Organization
Organization Name:HEART OF TEXAS INTERNAL MEDICINE ASSOCIATES, PA
Other - Org Name:BIG COUNTRY VEIN RELIEF
Other - Org Type:Doing Business As
Authorized Official - Title/Position:COO
Authorized Official - Prefix:MR
Authorized Official - First Name:BRYAN
Authorized Official - Middle Name:
Authorized Official - Last Name:WEST
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:325-643-3300
Mailing Address - Street 1:PO BOX 520
Mailing Address - Street 2:
Mailing Address - City:BROWNWOOD
Mailing Address - State:TX
Mailing Address - Zip Code:76804-0520
Mailing Address - Country:US
Mailing Address - Phone:325-643-3300
Mailing Address - Fax:325-641-8714
Practice Address - Street 1:4716 S 14TH ST
Practice Address - Street 2:
Practice Address - City:ABILENE
Practice Address - State:TX
Practice Address - Zip Code:79605-4733
Practice Address - Country:US
Practice Address - Phone:325-795-1200
Practice Address - Fax:325-795-1202
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-05-29
Last Update Date:2009-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX084917601Medicaid
TX00R82TOtherBCBS
TX00R82TMedicare PIN