Provider Demographics
NPI:1457623522
Name:DEBORAH B MCCOLLUM, MD PA
Entity Type:Organization
Organization Name:DEBORAH B MCCOLLUM, MD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DEBORAH
Authorized Official - Middle Name:BURGE
Authorized Official - Last Name:MCCOLLUM
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:806-457-9107
Mailing Address - Street 1:PO BOX 840026
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75284-0026
Mailing Address - Country:US
Mailing Address - Phone:806-212-6965
Mailing Address - Fax:806-212-6278
Practice Address - Street 1:6611 W AMARILLO BLVD
Practice Address - Street 2:
Practice Address - City:AMARILLO
Practice Address - State:TX
Practice Address - Zip Code:79106-1755
Practice Address - Country:US
Practice Address - Phone:806-212-4535
Practice Address - Fax:806-212-4555
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-02-03
Last Update Date:2020-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXJ83132086S0129X
208G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208G00000XAllopathic & Osteopathic PhysiciansThoracic Surgery (Cardiothoracic Vascular Surgery)Group - Multi-Specialty
No2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX046487702Medicaid