Provider Demographics
NPI:1780869065
Name:ROCKPORT MEDICAL CLINIC LLC
Entity type:Organization
Organization Name:ROCKPORT MEDICAL CLINIC LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER PROVIDER
Authorized Official - Prefix:MR
Authorized Official - First Name:RANDY
Authorized Official - Middle Name:D
Authorized Official - Last Name:BINGHAM
Authorized Official - Suffix:
Authorized Official - Credentials:PA
Authorized Official - Phone:361-790-9047
Mailing Address - Street 1:1704 JENKINS ST
Mailing Address - Street 2:
Mailing Address - City:ROCKPORT
Mailing Address - State:TX
Mailing Address - Zip Code:78382-3341
Mailing Address - Country:US
Mailing Address - Phone:361-790-9047
Mailing Address - Fax:361-790-9615
Practice Address - Street 1:1704 JENKINS ST
Practice Address - Street 2:
Practice Address - City:ROCKPORT
Practice Address - State:TX
Practice Address - Zip Code:78382-3341
Practice Address - Country:US
Practice Address - Phone:361-790-9047
Practice Address - Fax:361-790-9615
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-04
Last Update Date:2022-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX261QP2300X
TX673904261QR1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
No261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX0082RBOtherBLUE CROSS
TX196052801Medicaid
TX196052802OtherMEDICAID # FOR RURAL HEALTH CLINIC
TX196052801Medicaid
TX00Z184Medicare PIN