Provider Demographics
NPI:1750570008
Name:PICKETT HEART CLINIC
Entity type:Organization
Organization Name:PICKETT HEART CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:R
Authorized Official - Last Name:PICKETT
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:936-634-9844
Mailing Address - Street 1:1111 W FRANK AVE
Mailing Address - Street 2:SUITE 203
Mailing Address - City:LUFKIN
Mailing Address - State:TX
Mailing Address - Zip Code:75904-3303
Mailing Address - Country:US
Mailing Address - Phone:936-634-9844
Mailing Address - Fax:936-634-9258
Practice Address - Street 1:1111 W FRANK AVE
Practice Address - Street 2:SUITE 203
Practice Address - City:LUFKIN
Practice Address - State:TX
Practice Address - Zip Code:75904-3303
Practice Address - Country:US
Practice Address - Phone:936-634-9844
Practice Address - Fax:936-634-9258
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-22
Last Update Date:2010-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXE8818207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular DiseaseGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX146291301Medicaid
TXC20514Medicare UPIN
TX00852KMedicare PIN