Provider Demographics
NPI:1689651440
Name:MCLENNAN COUNTY MEDICAL EDUCATION AND RESEARCH FOUNDATION
Entity Type:Organization
Organization Name:MCLENNAN COUNTY MEDICAL EDUCATION AND RESEARCH FOUNDATION
Other - Org Name:FAMILY HEALTH CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:MRS
Authorized Official - First Name:ANNETTE
Authorized Official - Middle Name:
Authorized Official - Last Name:BALLEW
Authorized Official - Suffix:
Authorized Official - Credentials:CPA
Authorized Official - Phone:254-313-4282
Mailing Address - Street 1:1600 PROVIDENCE DR
Mailing Address - Street 2:
Mailing Address - City:WACO
Mailing Address - State:TX
Mailing Address - Zip Code:76707-2261
Mailing Address - Country:US
Mailing Address - Phone:254-313-4200
Mailing Address - Fax:254-313-4326
Practice Address - Street 1:1600 PROVIDENCE DR
Practice Address - Street 2:
Practice Address - City:WACO
Practice Address - State:TX
Practice Address - Zip Code:76707-2261
Practice Address - Country:US
Practice Address - Phone:254-313-4200
Practice Address - Fax:254-313-4531
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-12-22
Last Update Date:2016-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX121447001Medicaid
TX121447002Medicaid
TX121447003Medicaid
TX00L183Medicare ID - Type UnspecifiedGROUP PROVIDER NUMBER
TX121447001Medicaid