Provider Demographics
NPI:1649205972
Name:FMC MEDICAL FOUNDATION, INC.
Entity Type:Organization
Organization Name:FMC MEDICAL FOUNDATION, INC.
Other - Org Name:FAMILY MEDICINE CENTER ON COULTER
Other - Org Type:Doing Business As
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:806-350-7325
Mailing Address - Street 1:1500 S. COULTER
Mailing Address - Street 2:SUITE 6
Mailing Address - City:AMARILLO
Mailing Address - State:TX
Mailing Address - Zip Code:79106-1790
Mailing Address - Country:US
Mailing Address - Phone:806-467-9777
Mailing Address - Fax:806-467-9799
Practice Address - Street 1:1500 S. COULTER
Practice Address - Street 2:SUITE 6
Practice Address - City:AMARILLO
Practice Address - State:TX
Practice Address - Zip Code:79106-1790
Practice Address - Country:US
Practice Address - Phone:806-467-9777
Practice Address - Fax:806-467-9799
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-12
Last Update Date:2022-05-03
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
TX00248ROtherMEDICARE GROUP
TX45D0982647OtherCLIA
TX147805901Medicaid
TX0099GFOtherBCBS GROUP NUMBER
TX441892001OtherPALMETTO - DMERC
TXR26713OtherBUREAU OF RADIATION CONTR
TX441892001OtherPALMETTO - DMERC
TX45D0982647OtherCLIA
TX147805901Medicaid