Provider Demographics
NPI:1174726061
Name:FAMILY MEDICINE AT WILLOW BEND
Entity type:Organization
Organization Name:FAMILY MEDICINE AT WILLOW BEND
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:TAMMY
Authorized Official - Middle Name:TICKLE
Authorized Official - Last Name:KOMENDA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:972-608-1868
Mailing Address - Street 1:5944 W PARKER RD STE 100
Mailing Address - Street 2:
Mailing Address - City:PLANO
Mailing Address - State:TX
Mailing Address - Zip Code:75093-6422
Mailing Address - Country:US
Mailing Address - Phone:972-608-1868
Mailing Address - Fax:972-943-8644
Practice Address - Street 1:5944 W PARKER RD STE 100
Practice Address - Street 2:
Practice Address - City:PLANO
Practice Address - State:TX
Practice Address - Zip Code:75093-6422
Practice Address - Country:US
Practice Address - Phone:972-608-1868
Practice Address - Fax:972-943-8644
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-07
Last Update Date:2008-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXH6350261QH0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX10018514OtherAMERIGROUP PROVIDER #
TX165802301Medicaid
TX65802302Medicaid
TX8C0534Medicare ID - Type Unspecified2 OF 2 MEDICARE #'S
TX00964WMedicare ID - Type UnspecifiedONE OF 2 MEDICARE #'S
TXE21206Medicare UPIN