MEDICARE: DR. PATRICK LEROY MAHAN D. C.

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	111NX0100X	Occupational Health Chiropractor	DC 2748	TX

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	350043251	OTHER	TX	RAILROAD MEDICARE

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
2	601089	OTHER	TX	BLUE CROSS BLUE SHIELD

General Provider Information

NPI Number	:	1700818325
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. PATRICK LEROY MAHAN D. C.

Provider Business Mailing Address
First Line	:	302 E BEAUREGARD AVE
Second Line	:
City	:	SAN ANGELO
State	:	TX
Zip	:	76903-5923
Country	:	US
Telephone Number	:	325-655-1070
Fax Number	:	325-655-1036

Provider Business Practice Location Address
First Line	:	302 E BEAUREGARD AVE
Second Line	:
City	:	SAN ANGELO
State	:	TX
Zip	:	76903-5923
Country	:	US
Telephone Number	:	325-655-1070
Fax Number	:	325-655-1036

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/06/2006
Last Update Date	:	01/23/2009

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