MEDICARE: RIVERWALK CLINIC, LLC

Medicare Provider Information

Scope of Practice

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

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207Q00000X	Family Medicine Physician	J3984	TX
2	261QU0200X	Urgent Care Clinic/Center	J3984	TX

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

General Provider Information

NPI Number	:	1629191176
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	RIVERWALK CLINIC, LLC

Provider Business Mailing Address
First Line	:	5080 SPECTRUM DR
Second Line	:	SUITE 1200 WEST TOWER
City	:	ADDISON
State	:	TX
Zip	:	75001-4648
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1045 CENTRAL PARKWAY NORTH
Second Line	:	SUITE 200
City	:	SAN ANTONIO
State	:	TX
Zip	:	78232-5024
Country	:	US
Telephone Number	:	210-272-1741
Fax Number	:	210-272-1747

Authorized Official
Title or Position	:	OWNER
Name	:	WILLIAM TOM FOGARTY
Credential	:	MD
Telephone Number	:	972-364-8000

Provider Enumeration Date	:	04/09/2007
Last Update Date	:	06/12/2013

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Directions to “RIVERWALK CLINIC, LLC ” Practice Location

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