Provider Demographics
NPI:1912595018
Name:TEXAS PHYSICIAN SERVICES, PLLC
Entity Type:Organization
Organization Name:TEXAS PHYSICIAN SERVICES, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PROVIDER
Authorized Official - Prefix:
Authorized Official - First Name:KENNETH
Authorized Official - Middle Name:
Authorized Official - Last Name:MCCLURE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:903-720-6605
Mailing Address - Street 1:PO BOX 10298
Mailing Address - Street 2:
Mailing Address - City:LONGVIEW
Mailing Address - State:TX
Mailing Address - Zip Code:75608-0298
Mailing Address - Country:US
Mailing Address - Phone:903-720-6605
Mailing Address - Fax:866-842-1649
Practice Address - Street 1:615 CLINIC DR
Practice Address - Street 2:
Practice Address - City:LONGVIEW
Practice Address - State:TX
Practice Address - Zip Code:75605-5172
Practice Address - Country:US
Practice Address - Phone:903-720-6605
Practice Address - Fax:866-842-1649
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-01-05
Last Update Date:2021-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXL7479OtherMEDICAL LICENSE