Provider Demographics
NPI:1790976934
Name:NORTH COUNTRY FAMILY PRACTICE, PA
Entity Type:Organization
Organization Name:NORTH COUNTRY FAMILY PRACTICE, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:W
Authorized Official - Last Name:DOTTI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:817-329-8364
Mailing Address - Street 1:1050 E. HWY. 114
Mailing Address - Street 2:SUITE 100
Mailing Address - City:SOUTHLAKE
Mailing Address - State:TX
Mailing Address - Zip Code:76092-5242
Mailing Address - Country:US
Mailing Address - Phone:817-329-8364
Mailing Address - Fax:817-329-1285
Practice Address - Street 1:1050 E. HWY. 114
Practice Address - Street 2:SUITE 100
Practice Address - City:SOUTHLAKE
Practice Address - State:TX
Practice Address - Zip Code:76092-5242
Practice Address - Country:US
Practice Address - Phone:817-329-8364
Practice Address - Fax:817-329-1285
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-05
Last Update Date:2010-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX00R61WMedicare PIN