Provider Demographics
NPI:1679909915
Name:DISCOVERY MEDICAL NETWORK MATAGORDA, LLC
Entity Type:Organization
Organization Name:DISCOVERY MEDICAL NETWORK MATAGORDA, LLC
Other - Org Name:MATAGORDA MEDICAL GROUP
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:DERRELL
Authorized Official - Middle Name:M
Authorized Official - Last Name:HAVINS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:806-791-1591
Mailing Address - Street 1:2950 50TH ST
Mailing Address - Street 2:
Mailing Address - City:LUBBOCK
Mailing Address - State:TX
Mailing Address - Zip Code:79413-4326
Mailing Address - Country:US
Mailing Address - Phone:806-791-1591
Mailing Address - Fax:
Practice Address - Street 1:600 HOSPITAL CIR
Practice Address - Street 2:SUITE 201
Practice Address - City:BAY CITY
Practice Address - State:TX
Practice Address - Zip Code:77414-4755
Practice Address - Country:US
Practice Address - Phone:979-241-6100
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-09-18
Last Update Date:2013-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty