Provider Demographics
NPI:1396934147
Name:GRANBURY FAMILY MED CLINIC
Entity type:Organization
Organization Name:GRANBURY FAMILY MED CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:LOUIS
Authorized Official - Last Name:LEE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:817-573-3447
Mailing Address - Street 1:805 HILL BLVD
Mailing Address - Street 2:SUITE 103
Mailing Address - City:GRANBURY
Mailing Address - State:TX
Mailing Address - Zip Code:76048-1481
Mailing Address - Country:US
Mailing Address - Phone:817-573-3447
Mailing Address - Fax:
Practice Address - Street 1:805 HILL BLVD
Practice Address - Street 2:SUITE 103
Practice Address - City:GRANBURY
Practice Address - State:TX
Practice Address - Zip Code:76048-1482
Practice Address - Country:US
Practice Address - Phone:817-573-3447
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-17
Last Update Date:2008-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX145044701Medicaid
TX00402RMedicare PIN