Provider Demographics
NPI:1659620433
Name:CLEBURNE FAMILY MEDICINE ASSOCIATES, PLLC
Entity Type:Organization
Organization Name:CLEBURNE FAMILY MEDICINE ASSOCIATES, PLLC
Other - Org Name:FAMILY MEDICINE ASSOCIATES, P.A.
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:DANA
Authorized Official - Middle Name:OLIVE
Authorized Official - Last Name:GASSAWAY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:214-668-0414
Mailing Address - Street 1:251 E SOUTHLAKE BLVD
Mailing Address - Street 2:
Mailing Address - City:SOUTHLAKE
Mailing Address - State:TX
Mailing Address - Zip Code:76092-6269
Mailing Address - Country:US
Mailing Address - Phone:817-439-9205
Mailing Address - Fax:
Practice Address - Street 1:220 N. RIDGEWAY DR
Practice Address - Street 2:
Practice Address - City:CLEBURNE
Practice Address - State:TX
Practice Address - Zip Code:76033-4115
Practice Address - Country:US
Practice Address - Phone:817-556-4800
Practice Address - Fax:817-774-5015
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:FAMILY MEDICINE ASSOCIATES, P.A.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2012-09-07
Last Update Date:2024-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX00LK61OtherNEW MEDICARE - PENDING