MEDICARE: FAYETTEVILLE GROUP HEALTH, LLC

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	261QP2300X	Primary Care Clinic/Center

General Provider Information

NPI Number	:	1780380956
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	FAYETTEVILLE GROUP HEALTH, LLC

Provider Business Mailing Address
First Line	:	16131 N ELDRIDGE PKWY STE 100
Second Line	:
City	:	TOMBALL
State	:	TX
Zip	:	77377-9130
Country	:	US
Telephone Number	:	832-585-2747
Fax Number	:

Provider Business Practice Location Address
First Line	:	509 E MILLSAP RD STE 107
Second Line	:
City	:	FAYETTEVILLE
State	:	AR
Zip	:	72703-4862
Country	:	US
Telephone Number	:	281-429-8526
Fax Number	:

Authorized Official
Title or Position	:	BILLING MANAGER
Name	:	FELISHA WALKER
Credential	:
Telephone Number	:	281-429-8526

Provider Enumeration Date	:	01/31/2023
Last Update Date	:	01/31/2023

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