Provider Demographics
NPI:1750557641
Name:COPPER RIDGE MEDICAL PA
Entity type:Organization
Organization Name:COPPER RIDGE MEDICAL PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ANN
Authorized Official - Middle Name:
Authorized Official - Last Name:NOLEN
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:512-930-0363
Mailing Address - Street 1:7600 HIGHWAY 29 W
Mailing Address - Street 2:STE #5
Mailing Address - City:GEORGETOWN
Mailing Address - State:TX
Mailing Address - Zip Code:78628-6937
Mailing Address - Country:US
Mailing Address - Phone:512-930-0363
Mailing Address - Fax:512-930-0371
Practice Address - Street 1:7600 HIGHWAY 29 W
Practice Address - Street 2:STE #5
Practice Address - City:GEORGETOWN
Practice Address - State:TX
Practice Address - Zip Code:78628-6937
Practice Address - Country:US
Practice Address - Phone:512-930-0363
Practice Address - Fax:512-930-0371
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-01
Last Update Date:2009-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXG1494261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXG1494OtherPHYSICIAN STATE LICENSE