NPIMap

Organization Active NPI

Cleburne Internal Medicine Associates, PA

  • Internal Medicine Physician
  • Cleburne, TX
National Provider Identifier
1629162805
Registry record updated Aug 22, 2020
On this page

Key facts

NPPES NPI Registry
Primary specialty
Internal Medicine PhysicianTaxonomy code 207R00000X
Legal business name
CLEBURNE INTERNAL MEDICINE ASSOCIATES, PA
Practice address
141 Hyde Park Blvd
Cleburne, TX 76033-4561
Phone
(817) 641-5221
Fax
(817) 517-5241
NPI assigned
Oct 3, 2006
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Aug 22, 2020

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

Authorized official

Name
Dr. Brent Holmes Wallace, MDNPI 1386638252
Title
President
Phone
(817) 641-5221

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 1

Specialty (taxonomy)CodeLicenseStatePrimary
Internal Medicine PhysicianGroup: 193400000X SINGLE SPECIALTY GROUP 207R00000X Primary

Addresses

Primary practice location

141 Hyde Park Blvd
Cleburne, TX 76033-4561

Mailing address

141 Hyde Park Blvd
Cleburne, TX 76033-4561
Phone (817) 641-5221

Other identifiers 1

IdentifierTypeStateIssuer
00837NOtherTXBCBS GROUP NUMBER

National Provider Directory

National Provider Directory

Practitioners & affiliated clinicians

Practitioners 6

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles.

NPI Registry JSON

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

{
    "created_epoch": "1159833600000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1598054400000",
    "number": "1629162805",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "141 HYDE PARK BLVD",
            "city": "CLEBURNE",
            "state": "TX",
            "postal_code": "760334561",
            "telephone_number": "817-641-5221",
            "fax_number": "817-517-5241"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "141 HYDE PARK BLVD",
            "city": "CLEBURNE",
            "state": "TX",
            "postal_code": "760334561",
            "telephone_number": "817-641-5221",
            "fax_number": "817-517-5241"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "CLEBURNE INTERNAL MEDICINE ASSOCIATES, PA",
        "organizational_subpart": "NO",
        "enumeration_date": "2006-10-03",
        "last_updated": "2020-08-22",
        "status": "A",
        "authorized_official_last_name": "WALLACE",
        "authorized_official_first_name": "BRENT",
        "authorized_official_middle_name": "HOLMES",
        "authorized_official_title_or_position": "PRESIDENT",
        "authorized_official_telephone_number": "817-641-5221",
        "authorized_official_name_prefix": "Dr.",
        "authorized_official_credential": "MD"
    },
    "taxonomies": [
        {
            "code": "207R00000X",
            "taxonomy_group": "193400000X SINGLE SPECIALTY  GROUP",
            "desc": "Internal Medicine",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "BCBS GROUP NUMBER",
            "identifier": "00837N",
            "state": "TX"
        }
    ],
    "endpoints": [],
    "other_names": []
}

Other providers in Cleburne, TX

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Aug 22, 2020; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.