Provider Demographics
NPI:1003825852
Name:FMC MEDICAL FOUNDATION, INC
Entity type:Organization
Organization Name:FMC MEDICAL FOUNDATION, INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING SPECIALIST
Authorized Official - Prefix:
Authorized Official - First Name:STEFANIE
Authorized Official - Middle Name:
Authorized Official - Last Name:FEEMSTER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:806-358-9400
Mailing Address - Street 1:1500 S COULTER ST STE 1
Mailing Address - Street 2:
Mailing Address - City:AMARILLO
Mailing Address - State:TX
Mailing Address - Zip Code:79106-1787
Mailing Address - Country:US
Mailing Address - Phone:806-354-0404
Mailing Address - Fax:806-354-2810
Practice Address - Street 1:1500 S COULTER ST STE 1
Practice Address - Street 2:
Practice Address - City:AMARILLO
Practice Address - State:TX
Practice Address - Zip Code:79106-1787
Practice Address - Country:US
Practice Address - Phone:806-354-0404
Practice Address - Fax:806-354-2810
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-07
Last Update Date:2022-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX081138203Medicaid
TX134071303Medicaid
TX081138202Medicaid
TX081138201 TERM 12/16Medicaid
TX0077BMOtherBCBS
TX081138202Medicaid
TX081138203 NEWMedicaid