Individual Professional Information |
|
NPI
|
1447201157
|
|
Unique healthcare provider (clinician) ID assigned by NPPES
|
|
PECOS UID
|
0749226397
|
|
Unique individual clinician ID assigned by PECOS
|
|
Professional Enrollment ID
|
I20050705000794
|
|
Unique ID for the individual professional enrollment that is the source for the data in the observation
|
|
Provider Last Name
|
WITHAM
|
|
Individual professional last name
|
|
Provider First Name
|
WILLIAM
|
|
Individual professional first name
|
|
Provider Middle Name
|
ROBERT
|
|
Individual professional middle name
|
|
Provider Gender
|
M
|
|
The provider's gender if the provider is a person.
|
|
Provider Credential Text
|
MD
|
|
The abbreviations for professional degrees or credentials used or held by the provider, if the provider is an individual. Examples are MD, DDS, CSW, CNA, AA, NP, RNA, or PSY. These credential designations will not be verified by NPS.
|
Medical School Information |
|
Medical School Name
|
TEXAS TECH UNIVERSITY HEALTH SCIENCE CENTER SCHOOL OF MEDICINE
|
|
Individual professional's medical school
|
|
Graduation Year
|
2000
|
|
Individual professional's medical school graduation year
|
|
Primary Specialty
|
GENERAL SURGERY
|
|
Primary medical specialty reported by the individual professional in the selected enrollment
|
|
Secondary Specialty 1
|
PERIPHERAL VASCULAR DISEASE
|
|
First secondary medical specialty reported by the individual professional in the selected enrollment
|
|
All Secondary Specialties
|
PERIPHERAL VASCULAR DISEASE
|
|
All four secondary specialties reported by the individual professional in the selected enrollment, separated by commas
|
Practice Information |
|
Organization Legal Name
|
CHRISTUS TRINITY CLINIC
|
|
Legal name of the Group Practice that the individual professional works with- will be blank if the address is not linked to a Group Practice
|
|
Group Practice PAC ID
|
3072426741
|
|
Unique Group Practice ID assigned by PECOS to the Group Practice that the individual professional works with- will be blank if the address is not linked to a Group Practice
|
|
Number of Group Practice members
|
589
|
|
Total number of individual professionals affiliated with the Group Practice based on Group Practice PAC ID
|
|
Line 1 Street Address
|
115 AIRPORT RD
|
|
Group Practice or individual's line 1 address
|
|
City
|
SULPHUR SPRINGS
|
|
Group Practice or individual's city
|
|
State
|
TX
|
|
Group Practice or individual's state
|
|
Zip Code
|
754822105
|
|
Group Practice or individual's zip code (9 digits when available)
|
|
Phone Number
|
9038857671
|
|
Phone number is listed only when there is a single phone number available for the practice location address
|
Hospital(s) Affiliation Information |
|
Hospital Affiliation CCN 1
|
450135
|
|
Medicare CCN of hospital where individual professional provides service 1
|
|
Hospital Affiliation LBN 1
|
TEXAS HEALTH HARRIS METHODIST HOSPITAL FORT WORTH
|
|
Legal business name of hospital where individual professional provides service 1
|
|
Hospital Affiliation CCN 2
|
450236
|
|
Medicare CCN of hospital where individual professional provides service 2
|
|
Hospital Affiliation LBN 2
|
CHRISTUS MOTHER FRANCES HOSPITAL SULPHUR SPRINGS
|
|
Legal business name of hospital where individual professional provides service 2
|
|
Professional Accepts Medicare Assignment
|
Y
|
|
|