MEDICARE: COLLOM & CARNEY CLINIC ASSOCIATION

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QE0700X	End-Stage Renal Disease (ESRD) Treatment Clinic/Center	000189	TX

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
3	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1578545539
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	COLLOM & CARNEY CLINIC ASSOCIATION

Provider Business Mailing Address
First Line	:	4800 TEXAS BLVD
Second Line	:
City	:	TEXARKANA
State	:	TX
Zip	:	75503-3033
Country	:	US
Telephone Number	:	903-614-3600
Fax Number	:	903-792-0951

Provider Business Practice Location Address
First Line	:	606 LOOP 59
Second Line	:
City	:	ATLANTA
State	:	TX
Zip	:	75551-1510
Country	:	US
Telephone Number	:	903-614-3601
Fax Number	:	903-792-0951

Authorized Official
Title or Position	:	ADMINISTRATOR
Name	:	MS. PAT ROBERTS
Credential	:
Telephone Number	:	903-614-3601

Provider Enumeration Date	:	11/16/2005
Last Update Date	:	03/23/2010

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