Provider Demographics
NPI:1245445568
Name:THE MED CLINIC
Entity type:Organization
Organization Name:THE MED CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:FAMILY PRACTICE
Authorized Official - Prefix:MRS
Authorized Official - First Name:BEVERLY
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:ST. JULIEN
Authorized Official - Suffix:
Authorized Official - Credentials:NP, MD
Authorized Official - Phone:409-985-8100
Mailing Address - Street 1:3705 9TH AVE
Mailing Address - Street 2:
Mailing Address - City:PORT ARTHUR
Mailing Address - State:TX
Mailing Address - Zip Code:77642-4423
Mailing Address - Country:US
Mailing Address - Phone:409-985-8100
Mailing Address - Fax:409-985-4778
Practice Address - Street 1:3705 9TH AVE
Practice Address - Street 2:
Practice Address - City:PORT ARTHUR
Practice Address - State:TX
Practice Address - Zip Code:77642-4423
Practice Address - Country:US
Practice Address - Phone:409-985-8100
Practice Address - Fax:409-985-4778
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-11
Last Update Date:2015-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX465574363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX088281301Medicaid
TXNP0261Medicare PIN
TX088281301Medicaid