Provider Demographics
NPI:1679554844
Name:SANGER AVENUE MEDICAL
Entity type:Organization
Organization Name:SANGER AVENUE MEDICAL
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CLINIC ADMINISTRATOR
Authorized Official - Prefix:DR
Authorized Official - First Name:DOUGLAS
Authorized Official - Middle Name:L
Authorized Official - Last Name:HORNER
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:254-752-2300
Mailing Address - Street 1:6614 SANGER AVE
Mailing Address - Street 2:
Mailing Address - City:WACO
Mailing Address - State:TX
Mailing Address - Zip Code:76710-4253
Mailing Address - Country:US
Mailing Address - Phone:254-752-2300
Mailing Address - Fax:254-752-9436
Practice Address - Street 1:6614 SANGER AVE
Practice Address - Street 2:
Practice Address - City:WACO
Practice Address - State:TX
Practice Address - Zip Code:76710-4253
Practice Address - Country:US
Practice Address - Phone:254-752-2300
Practice Address - Fax:254-752-9436
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-11-07
Last Update Date:2008-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXJ8840207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX121360505Medicaid
TXG08208Medicare UPIN
TX121360505Medicaid