Healthcare Provider Details

I. General information

NPI: 1902686116
Provider Name (Legal Business Name): FRONTLINE MOBILE HEALTH
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/04/2023
Last Update Date: 10/04/2023
Certification Date: 10/04/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6517 N LAKEWOOD DR
GEORGETOWN TX
78633-9530
US

IV. Provider business mailing address

6517 N LAKEWOOD DR
GEORGETOWN TX
78633-9530
US

V. Phone/Fax

Practice location:
  • Phone: 512-838-3808
  • Fax: 512-253-2861
Mailing address:
  • Phone: 512-838-3808
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QA0505X
TaxonomyAdult Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: RUSSELL BURNHAM
Title or Position: CEO
Credential: APA-C
Phone: 512-838-3808