Healthcare Provider Details

I. General information

NPI: 1700946118
Provider Name (Legal Business Name): FAMILY MEDICAL CENTER OF GEORGETOWN, PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/08/2006
Last Update Date: 07/01/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

908 ROCKMOOR DR
GEORGETOWN TX
78628-8966
US

IV. Provider business mailing address

PO BOX 2509
GEORGETOWN TX
78627-2509
US

V. Phone/Fax

Practice location:
  • Phone: 512-868-0901
  • Fax: 512-868-1527
Mailing address:
  • Phone: 512-868-0901
  • Fax: 512-868-1527

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: RICHARD E OTTO
Title or Position: CO-OWNER
Credential: MD
Phone: 512-868-0901