Healthcare Provider Details

I. General information

NPI: 1033145545
Provider Name (Legal Business Name): FREDERICKSBURG CLINIC, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/25/2006
Last Update Date: 11/20/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1308 SOUTH HIGHWAY 16
FREDERICKSBURG TX
78624-5058
US

IV. Provider business mailing address

1308 SOUTH HIGHWAY 16
FREDERICKSBURG TX
78624-5058
US

V. Phone/Fax

Practice location:
  • Phone: 830-997-2181
  • Fax: 830-997-9598
Mailing address:
  • Phone: 830-997-2181
  • Fax: 830-997-9598

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number StateTX

VIII. Authorized Official

Name: JOHN RADCLIFFE KOTHMANN
Title or Position: AUTHORIZED OFFICIAL
Credential: M.D.
Phone: 830-997-2181