Basic Information
| Provider Information | |||||||||
| NPI: | 1801893656 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CLEBURNE FAMILY MEDICINE ASSOCIATES, PLLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | FAMILY MEDICINE ASSOCIATES | ||||||||
| OtherOrganizationType: | 4 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 220 N RIDGEWAY DR | ||||||||
| Address2: | |||||||||
| City: | CLEBURNE | ||||||||
| State: | TX | ||||||||
| PostalCode: | 760334115 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8175564800 | ||||||||
| FaxNumber: | 8177745015 | ||||||||
| Practice Location | |||||||||
| Address1: | 220 N RIDGEWAY DR | ||||||||
| Address2: | |||||||||
| City: | CLEBURNE | ||||||||
| State: | TX | ||||||||
| PostalCode: | 760334115 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8175564800 | ||||||||
| FaxNumber: | 8177745015 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/07/2005 | ||||||||
| LastUpdateDate: | 07/21/2022 | ||||||||
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| AuthorizedOfficialLastName: | JOHNSON | ||||||||
| AuthorizedOfficialFirstName: | JOE | ||||||||
| AuthorizedOfficialMiddleName: | STAN | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER/PARTNER | ||||||||
| AuthorizedOfficialTelephone: | 8175564800 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | TX | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 112652602 | 05 | TX | MEDICAID |