Provider Demographics
NPI:1912902826
Name:STEPHENVILLE MEDICAL AND SURGICAL CLINIC PA
Entity Type:Organization
Organization Name:STEPHENVILLE MEDICAL AND SURGICAL CLINIC PA
Other - Org Name:SMSC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHYSICIAN CLINIC ADMINISTRATOR
Authorized Official - Prefix:DR
Authorized Official - First Name:JANIE
Authorized Official - Middle Name:
Authorized Official - Last Name:MCMILLION
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:254-968-6051
Mailing Address - Street 1:150 RIVER NORTH BLVD
Mailing Address - Street 2:
Mailing Address - City:STEPHENVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:76401-1803
Mailing Address - Country:US
Mailing Address - Phone:254-968-6051
Mailing Address - Fax:254-968-4950
Practice Address - Street 1:150 RIVER NORTH BLVD
Practice Address - Street 2:
Practice Address - City:STEPHENVILLE
Practice Address - State:TX
Practice Address - Zip Code:76401-1803
Practice Address - Country:US
Practice Address - Phone:254-968-6051
Practice Address - Fax:254-968-4950
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-06-16
Last Update Date:2014-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXNA207Q00000X, 207RC0000X
207Q00000X, 207RC0000X, 207U00000X, 207V00000X, 207X00000X, 207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular DiseaseGroup - Multi-Specialty
No207U00000XAllopathic & Osteopathic PhysiciansNuclear MedicineGroup - Multi-Specialty
No207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Multi-Specialty
No207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Multi-Specialty
No207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX112052901Medicaid
TX112052902Medicaid
TX00E762OtherGROUP BCBS PROVIDER NUMBE
TX0411240001OtherDME CIGNA GOVERNMENT SERV
TXCA8089OtherGROUP RAILROAD MEDICARE #
TX=========003OtherCHAMPUS GROUP NUMBER
TX112052901Medicaid
TX=========003OtherCHAMPUS GROUP NUMBER
TX112052902Medicaid