Provider Demographics
NPI:1255397469
Name:CMG FAMILY CLINIC OF TEXARKANA
Entity type:Organization
Organization Name:CMG FAMILY CLINIC OF TEXARKANA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO/PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:DONNA
Authorized Official - Middle Name:J
Authorized Official - Last Name:MIKULECKY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:713-277-2208
Mailing Address - Street 1:401 EAST ST
Mailing Address - Street 2:
Mailing Address - City:TEXARKANA
Mailing Address - State:AR
Mailing Address - Zip Code:71854-6507
Mailing Address - Country:US
Mailing Address - Phone:870-773-2177
Mailing Address - Fax:870-773-2758
Practice Address - Street 1:401 EAST ST
Practice Address - Street 2:
Practice Address - City:TEXARKANA
Practice Address - State:AR
Practice Address - Zip Code:71854-6507
Practice Address - Country:US
Practice Address - Phone:870-773-2177
Practice Address - Fax:870-773-2758
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-25
Last Update Date:2008-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX081267903Medicaid
AR127508002Medicaid
TX081267904Medicaid
TX081267904Medicaid
AR127508002Medicaid