Provider Demographics
NPI:1700150869
Name:FAMILY MEDICINE RURAL HEALTH CLINIC, PA
Entity Type:Organization
Organization Name:FAMILY MEDICINE RURAL HEALTH CLINIC, PA
Other - Org Name:FAMILY MEDICINE CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:S
Authorized Official - Last Name:LANE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:512-556-3621
Mailing Address - Street 1:207 W AVENUE E
Mailing Address - Street 2:
Mailing Address - City:LAMPASAS
Mailing Address - State:TX
Mailing Address - Zip Code:76550-1820
Mailing Address - Country:US
Mailing Address - Phone:512-556-3621
Mailing Address - Fax:512-556-4080
Practice Address - Street 1:2401 WALKER PLACE BLVD
Practice Address - Street 2:
Practice Address - City:COPPERAS COVE
Practice Address - State:TX
Practice Address - Zip Code:76522-4025
Practice Address - Country:US
Practice Address - Phone:254-547-5516
Practice Address - Fax:254-542-0039
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-03-06
Last Update Date:2017-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
207Q00000X, 208000000X
TX261QR1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
No261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural HealthGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX121186403Medicaid
TX121186402Medicaid
TX458905OtherRHC MEDICARE ID
TX00U72JOtherMEDICARE B
TX121186401Medicaid
TX121186401Medicaid