Provider Demographics
NPI:1770660136
Name:ICW TA
Entity Type:Organization
Organization Name:ICW TA
Other - Org Name:FAMILY HEALTH CLINIC OF TEXOMA
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:SHAWN
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:MS, PA-C
Authorized Official - Phone:940-851-9900
Mailing Address - Street 1:1411 13TH ST STE 2
Mailing Address - Street 2:
Mailing Address - City:WICHITA FALLS
Mailing Address - State:TX
Mailing Address - Zip Code:76301-7100
Mailing Address - Country:US
Mailing Address - Phone:940-851-9900
Mailing Address - Fax:940-851-8089
Practice Address - Street 1:1411 13TH ST
Practice Address - Street 2:
Practice Address - City:WICHITA FALLS
Practice Address - State:TX
Practice Address - Zip Code:76301-7100
Practice Address - Country:US
Practice Address - Phone:940-851-9900
Practice Address - Fax:940-851-8089
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-01
Last Update Date:2008-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA00159363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX17262701Medicaid
TX172462702Medicaid
TX0056MGOtherBCBS
TX00410YMedicare PIN
TX172462702Medicaid