NPIMap

Organization Active NPI

Fredericksburg Clinic, PLLC

  • Family Medicine Physician
  • Fredericksburg, TX
National Provider Identifier
1033145545
Registry record updated Nov 20, 2017
On this page

Key facts

NPPES NPI Registry
Primary specialty
Family Medicine PhysicianTaxonomy code 207Q00000X
Legal business name
FREDERICKSBURG CLINIC, PLLC
Practice address
1308 South Highway 16
Fredericksburg, TX 78624-5058
Phone
(830) 997-2181
Fax
(830) 997-9598
NPI assigned
Jun 25, 2006
Last updated
Nov 20, 2017By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Nov 20, 2017

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
John Radcliffe Kothmann, M.D.NPI 1780624502
Title
Authorized Official
Phone
(830) 997-2181

Authorized official NPPES reports the official by name only. The link goes to the one practitioner connected to this organization with that name.

Specialties & licenses 2

Specialty (taxonomy)CodeLicenseStatePrimary
Family Medicine Physician 207Q00000X TX Primary
Internal Medicine Physician 207R00000X TX

Addresses

Primary practice location

1308 South Highway 16
Fredericksburg, TX 78624-5058

Mailing address

1308 South Highway 16
Fredericksburg, TX 78624-5058
Phone (830) 997-2181

Other identifiers 2

IdentifierTypeStateIssuer
082891502MedicaidTX
084372401MedicaidTX

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in TX

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20040812000578 TX Part B Supplier - Clinic/Group Practice 3375515992 Receives reassigned benefits from 13 practitioners
Practice locations: Fredericksburg, TX

National Provider Directory

National Provider Directory

Locations

1308 S State Highway 16
Fredericksburg, TX 78624
Phone (830) 997-2181

Practitioners & affiliated clinicians

Practitioners 14

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

View all 14

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1151193600000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1511136000000",
    "number": "1033145545",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "1308 SOUTH HIGHWAY 16",
            "city": "FREDERICKSBURG",
            "state": "TX",
            "postal_code": "786245058",
            "telephone_number": "830-997-2181",
            "fax_number": "830-997-9598"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1308 SOUTH HIGHWAY 16",
            "city": "FREDERICKSBURG",
            "state": "TX",
            "postal_code": "786245058",
            "telephone_number": "830-997-2181",
            "fax_number": "830-997-9598"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "FREDERICKSBURG CLINIC, PLLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2006-06-25",
        "last_updated": "2017-11-20",
        "status": "A",
        "authorized_official_last_name": "KOTHMANN",
        "authorized_official_first_name": "JOHN",
        "authorized_official_middle_name": "RADCLIFFE",
        "authorized_official_title_or_position": "AUTHORIZED OFFICIAL",
        "authorized_official_telephone_number": "830-997-2181",
        "authorized_official_credential": "M.D."
    },
    "taxonomies": [
        {
            "code": "207Q00000X",
            "taxonomy_group": "",
            "desc": "Family Medicine",
            "state": "TX",
            "license": null,
            "primary": true
        },
        {
            "code": "207R00000X",
            "taxonomy_group": "",
            "desc": "Internal Medicine",
            "state": "TX",
            "license": null,
            "primary": false
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "082891502",
            "state": "TX"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "084372401",
            "state": "TX"
        }
    ],
    "endpoints": [],
    "other_names": []
}

Other providers in Fredericksburg, TX

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Nov 20, 2017; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.