Provider Demographics
NPI:1801317722
Name:FAIRMOUNT FAMILY PRACTICE, PLLC
Entity type:Organization
Organization Name:FAIRMOUNT FAMILY PRACTICE, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING ADMINISTRATION
Authorized Official - Prefix:
Authorized Official - First Name:PRISCILLA
Authorized Official - Middle Name:
Authorized Official - Last Name:PIPES
Authorized Official - Suffix:
Authorized Official - Credentials:RHIT
Authorized Official - Phone:936-615-4265
Mailing Address - Street 1:3732 FAIRDALE RD
Mailing Address - Street 2:
Mailing Address - City:HEMPHILL
Mailing Address - State:TX
Mailing Address - Zip Code:75948
Mailing Address - Country:US
Mailing Address - Phone:409-579-2044
Mailing Address - Fax:409-579-2104
Practice Address - Street 1:3732 FAIRDALE RD
Practice Address - Street 2:
Practice Address - City:HEMPHILL
Practice Address - State:TX
Practice Address - Zip Code:75948
Practice Address - Country:US
Practice Address - Phone:409-579-2044
Practice Address - Fax:409-579-2104
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-06-30
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAP123751261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1922114206OtherNPI