MEDICARE: COVENANT MEDICAL GROUP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy
1	208600000X	Surgery Physician
2	208M00000X	Hospitalist Physician
3	207X00000X	Orthopaedic Surgery Physician
4	208000000X	Pediatrics Physician
5	207K00000X	Allergy & Immunology Physician
6	207L00000X	Anesthesiology Physician
7	207N00000X	Dermatology Physician
8	207R00000X	Internal Medicine Physician
9	207T00000X	Neurological Surgery Physician
10	207V00000X	Obstetrics & Gynecology Physician
11	207Q00000X	Family Medicine Physician

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	NM007E61	OTHER	NM	BCBS NM
3	0038GH	OTHER	TX	BCBS TX
4	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
5	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1376598904
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	COVENANT MEDICAL GROUP

Provider Business Mailing Address
First Line	:	2215 NASHVILLE AVE
Second Line	:
City	:	LUBBOCK
State	:	TX
Zip	:	79410-1105
Country	:	US
Telephone Number	:	806-725-5844
Fax Number	:	806-723-6532

Provider Business Practice Location Address
First Line	:	2215 NASHVILLE AVE
Second Line	:
City	:	LUBBOCK
State	:	TX
Zip	:	79410-1105
Country	:	US
Telephone Number	:	806-725-4800
Fax Number	:	806-723-6532

Authorized Official
Title or Position	:	COO
Name	:	KRISTEN KOTHMANN
Credential	:
Telephone Number	:	806-725-4800

Provider Enumeration Date	:	05/23/2006
Last Update Date	:	09/23/2020

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Directions to “COVENANT MEDICAL GROUP ” Practice Location

Language	Start Address	Practice Location

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