NPIMap

Organization Active NPI

Crockett Medical Center, LLC

Doing business as Crockett Medical Center Clinic

  • Family Medicine Physician
  • Crockett, TX
National Provider Identifier
1487155990
Registry record updated Aug 28, 2018
On this page

Key facts

NPPES NPI Registry
Primary specialty
Family Medicine PhysicianTaxonomy code 207Q00000X
Legal business name
CROCKETT MEDICAL CENTER, LLC
Doing business as
Crockett Medical Center Clinic
Practice address
1050 E Loop 304
Crockett, TX 75835
Phone
(936) 546-3890
NPI assigned
Feb 21, 2018
Last updated
Aug 28, 2018By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Aug 28, 2018

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

Authorized official

Name
Kelly Eugene TjelmelandNPI 1003900119
Title
Ceo
Phone
(512) 617-7500

Authorized official NPPES reports the official by name only. The link goes to the one practitioner with that name whose NPPES practice address or phone number is this organization’s.

Specialties & licenses 6

Specialty (taxonomy)CodeLicenseStatePrimary
Family Medicine Physician 207Q00000X TX Primary
Internal Medicine Physician 207R00000X TX
Cardiovascular Disease Physician 207RC0000X TX
Interventional Cardiology Physician 207RI0011X TX
Orthopaedic Surgery Physician 207X00000X TX
Urology Physician 208800000X TX

Addresses

Primary practice location

1050 E Loop 304
Crockett, TX 75835

Mailing address

4220 Bull Creek Rd
Austin, TX 78731-6026
Phone (512) 617-7500

Other identifiers 3

IdentifierTypeStateIssuer
385139603MedicaidTX
385139601MedicaidTX
385139602MedicaidTX

Other names 1

  • Crockett Medical Center Clinic Doing business as

Medicare participation

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

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20180316002045 TX Part B Supplier - Clinic/Group Practice 3173884152 Receives reassigned benefits from 7 practitioners
Practice locations: Crockett, TX

Other NPIs with the same Medicare PAC ID 2

NPIs whose Medicare enrollments share a PECOS associate control ID (the same enrolled entity).

National Provider Directory

National Provider Directory

Member of 1

Organizations this organization is a member of, according to the National Provider Directory.

Locations

1050 E Loop 304
Ste 201
Crockett, TX 75835
Phone (936) 546-3890

Practitioners & affiliated clinicians

Practitioners 8

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.

NPI Registry JSON

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

{
    "created_epoch": "1519171200000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1535414400000",
    "number": "1487155990",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "4220 BULL CREEK RD",
            "city": "AUSTIN",
            "state": "TX",
            "postal_code": "787316026",
            "telephone_number": "512-617-7500"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1050 E LOOP 304",
            "city": "CROCKETT",
            "state": "TX",
            "postal_code": "75835",
            "telephone_number": "936-546-3890"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "CROCKETT MEDICAL CENTER, LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2018-02-21",
        "last_updated": "2018-08-28",
        "status": "A",
        "authorized_official_last_name": "TJELMELAND",
        "authorized_official_first_name": "KELLY",
        "authorized_official_middle_name": "EUGENE",
        "authorized_official_title_or_position": "CEO",
        "authorized_official_telephone_number": "512-617-7500"
    },
    "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
        },
        {
            "code": "207RC0000X",
            "taxonomy_group": "",
            "desc": "Internal Medicine, Cardiovascular Disease",
            "state": "TX",
            "license": null,
            "primary": false
        },
        {
            "code": "207RI0011X",
            "taxonomy_group": "",
            "desc": "Internal Medicine, Interventional Cardiology",
            "state": "TX",
            "license": null,
            "primary": false
        },
        {
            "code": "207X00000X",
            "taxonomy_group": "",
            "desc": "Orthopaedic Surgery",
            "state": "TX",
            "license": null,
            "primary": false
        },
        {
            "code": "208800000X",
            "taxonomy_group": "",
            "desc": "Urology",
            "state": "TX",
            "license": null,
            "primary": false
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "385139603",
            "state": "TX"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "385139601",
            "state": "TX"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "385139602",
            "state": "TX"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Crockett Medical Center Clinic",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Crockett, TX

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Aug 28, 2018; 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.