=====================================================
General NPI Number Information
=====================================================
NPI Number | 1154496743
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | GIDMEC, LP
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/21/2006
-----------------------------------------------------
Last Update Date | 05/01/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 721 E AUSTIN ST
-----------------------------------------------------
City | GIDDINGS
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78942-3403
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 979-542-9519
-----------------------------------------------------
Fax | 979-542-9428
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 270
-----------------------------------------------------
City | GIDDINGS
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78942-0270
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 979-542-9519
-----------------------------------------------------
Fax | 979-542-9428
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CLINIC ADMINISTRATOR
-----------------------------------------------------
Name | KENNETH WALKER
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 325-695-5440
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | K6878
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------