Provider Demographics
NPI:1841569985
Name:SMG SIGNATURE MEDICAL GROUP
Entity Type:Organization
Organization Name:SMG SIGNATURE MEDICAL GROUP
Other - Org Name:TGMA WHARTON RURAL HEALTH CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:RANDY
Authorized Official - Middle Name:
Authorized Official - Last Name:SLACK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:979-282-6100
Mailing Address - Street 1:PO BOX 841648
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75284-1648
Mailing Address - Country:US
Mailing Address - Phone:979-282-6800
Mailing Address - Fax:979-282-6805
Practice Address - Street 1:2022 REGIONAL MEDICAL DR
Practice Address - Street 2:SUITE 1319
Practice Address - City:WHARTON
Practice Address - State:TX
Practice Address - Zip Code:77488-7231
Practice Address - Country:US
Practice Address - Phone:979-282-6800
Practice Address - Fax:979-282-6805
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-12-19
Last Update Date:2011-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health