Provider Demographics
NPI:1740458207
Name:MCH PROFESSIONAL CARE
Entity type:Organization
Organization Name:MCH PROFESSIONAL CARE
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:ASSISTANT DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:ELLEN
Authorized Official - Last Name:CONWAY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:432-640-2401
Mailing Address - Street 1:PO BOX 643
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46206-0643
Mailing Address - Country:US
Mailing Address - Phone:432-640-2401
Mailing Address - Fax:
Practice Address - Street 1:500 W 4TH ST
Practice Address - Street 2:
Practice Address - City:ODESSA
Practice Address - State:TX
Practice Address - Zip Code:79761-5001
Practice Address - Country:US
Practice Address - Phone:432-640-2401
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MCH PROFESSIONAL CARE
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-02-18
Last Update Date:2009-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX197485901Medicaid
TX0065JHOtherBLUE CROSS BLUE SHIELD
TX0065JHOtherBLUE CROSS BLUE SHIELD