Provider Demographics
NPI:1689645376
Name:PARKSIDE FAMILY CLINIC, PA
Entity type:Organization
Organization Name:PARKSIDE FAMILY CLINIC, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:R
Authorized Official - Last Name:MCLEOD
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:361-275-2800
Mailing Address - Street 1:1109 E BROADWAY ST
Mailing Address - Street 2:
Mailing Address - City:CUERO
Mailing Address - State:TX
Mailing Address - Zip Code:77954-2108
Mailing Address - Country:US
Mailing Address - Phone:361-275-2800
Mailing Address - Fax:361-275-8791
Practice Address - Street 1:1109 E BROADWAY ST
Practice Address - Street 2:
Practice Address - City:CUERO
Practice Address - State:TX
Practice Address - Zip Code:77954-2108
Practice Address - Country:US
Practice Address - Phone:361-275-2800
Practice Address - Fax:361-275-8791
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-01-30
Last Update Date:2011-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX164281101Medicaid
TX179346502Medicaid
TXDB6498OtherRR MCR
TX179346501Medicaid
TX164281102Medicaid
TX179346503Medicaid
TX179346503Medicaid
TX179346502Medicaid