1962424846 NPI number — PILOT POINT MEDICAL CLINIC, P.A.

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1962424846 NPI number — PILOT POINT MEDICAL CLINIC, P.A.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PILOT POINT MEDICAL CLINIC, P.A.
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
KENNETH W. BERESFORD, M.D., P.A.
Provider Other Organization Name Type Code:
4
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1962424846
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/12/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 1117
Provider Second Line Business Mailing Address:
1246 HWY 377 SOUTH SUITE 200
Provider Business Mailing Address City Name:
PILOT POINT
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
76258-1117
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
940-686-2254
Provider Business Mailing Address Fax Number:
940-686-2830

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1246 S HIGHWAY 377
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PILOT POINT
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
76258-4375
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
940-686-2254
Provider Business Practice Location Address Fax Number:
940-686-2830
Provider Enumeration Date:
07/23/2006

Additional Information

Authorized Official

Authorized Official Last Name:
BERESFORD
Authorized Official First Name:
KENNETH
Authorized Official Middle Name:
WAYNE
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
940-686-2254

Provider Taxonomy Codes

  • Taxonomy code: 261QP2300X , with the licence number:  K9226 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 045386202 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 0A3440 . This is a "MEDICARE GROUP PTAN" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 8F20689 . This is a "MEDICARE INDIV PTAN INDVID NPI" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 0A3440 . This is a "MEDICARE INDIVID PTAN FOR GRP NPI" identifier . This identifiers is of the category "OTHER".




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