Healthcare Provider Details

I. General information

NPI: 1871571737
Provider Name (Legal Business Name): NEW BOSTON MEDICAL GROUP LLP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/02/2006
Last Update Date: 04/13/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

114 W US HIGHWAY 82
NEW BOSTON TX
75570-2804
US

IV. Provider business mailing address

114 W US HIGHWAY 82
NEW BOSTON TX
75570-2804
US

V. Phone/Fax

Practice location:
  • Phone: 903-628-0422
  • Fax: 903-628-0448
Mailing address:
  • Phone: 903-628-0422
  • Fax: 903-628-0448

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License NumberK90258
License Number StateTX
# 2
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License NumberK0219
License Number StateTX
# 3
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA03545
License Number StateTX
# 4
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number564395
License Number StateTX
# 5
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number660180
License Number StateTX

VIII. Authorized Official

Name: DONALD STRATTON DOUGLAS
Title or Position: SUPERVISING PHYSICIAN
Credential: M.D.
Phone: 903-628-0422