Provider Demographics
NPI:1649616251
Name:AIC PRIMARY CARE PLLC
Entity type:Organization
Organization Name:AIC PRIMARY CARE PLLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:HR GENERALIST/ CREDENTIALING
Authorized Official - Prefix:
Authorized Official - First Name:MEGAN
Authorized Official - Middle Name:
Authorized Official - Last Name:JEFFERSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:281-886-8964
Mailing Address - Street 1:2600 FM 1764 SUITE 190
Mailing Address - Street 2:
Mailing Address - City:LA MARQUE
Mailing Address - State:TX
Mailing Address - Zip Code:77568
Mailing Address - Country:US
Mailing Address - Phone:281-886-8964
Mailing Address - Fax:
Practice Address - Street 1:2600 FM 1764 SUITE 190
Practice Address - Street 2:
Practice Address - City:LA MARQUE
Practice Address - State:TX
Practice Address - Zip Code:77568
Practice Address - Country:US
Practice Address - Phone:281-886-8964
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-05-22
Last Update Date:2016-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXL9314207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXB148230Medicare PIN