Provider Demographics
NPI:1851538565
Name:GEORGETOWN FAMILY & GERIATRIC MEDICINE PLLC
Entity Type:Organization
Organization Name:GEORGETOWN FAMILY & GERIATRIC MEDICINE PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:ROGELIO
Authorized Official - Middle Name:
Authorized Official - Last Name:TREVINO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:512-869-4800
Mailing Address - Street 1:103 THOUSAND OAKS BLVD
Mailing Address - Street 2:
Mailing Address - City:GEORGETOWN
Mailing Address - State:TX
Mailing Address - Zip Code:78628-8757
Mailing Address - Country:US
Mailing Address - Phone:512-869-4800
Mailing Address - Fax:512-869-4807
Practice Address - Street 1:103 THOUSAND OAKS BLVD
Practice Address - Street 2:
Practice Address - City:GEORGETOWN
Practice Address - State:TX
Practice Address - Zip Code:78628-8757
Practice Address - Country:US
Practice Address - Phone:512-869-4800
Practice Address - Fax:512-869-4807
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-01-16
Last Update Date:2010-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX207Q00000X, 207QG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207QG0300XAllopathic & Osteopathic PhysiciansFamily MedicineGeriatric MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX0010SAOtherBCBSTX GROUP #
TX201407801Medicaid
TX0A3369Medicare PIN