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General NPI Number Information
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NPI Number | 1043901788
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Entity Type | Organization
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Legal Business Name | PRIMARY CARE OF EAGLE PASS PLLC
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Dates
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Enumeration Date | 05/15/2023
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Last Update Date | 09/26/2023
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Provider Practice Location Address
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Address Line | 1975 N VETERANS BLVD STE 9
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City | EAGLE PASS
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State | TX
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Zip | 78852-4456
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Country | US
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Telephone | 830-213-8186
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Fax | 830-213-8157
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Provider Business Mailing Address
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Address Line | 1975 N VETERANS BLVD STE 9
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City | EAGLE PASS
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State | TX
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Zip | 78852-4456
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Country | US
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Telephone | 830-213-8186
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Fax | 830-213-8157
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Authorized Official
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Title or Position | SOLE MEMBER
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Name | DAVID W CHISUM
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Credential | MD
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Telephone | 830-213-8186
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number |
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License Number State |
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