Provider Demographics
NPI:1922021823
Name:ISLAND CLINIC, P.A.
Entity type:Organization
Organization Name:ISLAND CLINIC, P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:D
Authorized Official - Last Name:THORLEY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:409-744-6373
Mailing Address - Street 1:6511 STEWART RD
Mailing Address - Street 2:SUITE # 1
Mailing Address - City:GALVESTON
Mailing Address - State:TX
Mailing Address - Zip Code:77551-1837
Mailing Address - Country:US
Mailing Address - Phone:409-744-6373
Mailing Address - Fax:409-744-9300
Practice Address - Street 1:6511 STEWART RD
Practice Address - Street 2:SUITE # 1
Practice Address - City:GALVESTON
Practice Address - State:TX
Practice Address - Zip Code:77551-1837
Practice Address - Country:US
Practice Address - Phone:409-744-6373
Practice Address - Fax:409-744-9300
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-25
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX302F00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes302F00000XManaged Care OrganizationsExclusive Provider Organization
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXB26964Medicare UPIN
TX00R263Medicare ID - Type UnspecifiedPROVIDER NUMBER