Provider Demographics
NPI:1396781761
Name:MAINLAND FAMILY PRACTICE, P.A.
Entity type:Organization
Organization Name:MAINLAND FAMILY PRACTICE, P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:FAN
Authorized Official - Middle Name:
Authorized Official - Last Name:LI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:409-935-8400
Mailing Address - Street 1:308 PINNACLE COVE CT
Mailing Address - Street 2:
Mailing Address - City:LEAGUE CITY
Mailing Address - State:TX
Mailing Address - Zip Code:77573-0856
Mailing Address - Country:US
Mailing Address - Phone:409-256-3639
Mailing Address - Fax:281-334-5763
Practice Address - Street 1:6807 EMMETT F LOWRY EXPY
Practice Address - Street 2:SUITE 300
Practice Address - City:TEXAS CITY
Practice Address - State:TX
Practice Address - Zip Code:77591-2546
Practice Address - Country:US
Practice Address - Phone:409-935-8400
Practice Address - Fax:409-935-8404
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-22
Last Update Date:2007-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXL0378207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX00W564Medicare ID - Type Unspecified
TXH25741Medicare UPIN