NPIMap

Organization Active NPI

Collom and Carney Clinic Association

  • Dermatology Physician
  • Texarkana, TX
National Provider Identifier
1891777611
Registry record updated Feb 24, 2023
On this page

Key facts

NPPES NPI Registry
Primary specialty
Dermatology PhysicianTaxonomy code 207N00000X
Legal business name
COLLOM AND CARNEY CLINIC ASSOCIATION
Practice address
5002 Cowhorn Creek Rd
Texarkana, TX 75503
Phone
(903) 614-3000
Fax
(903) 614-3525
NPI assigned
Nov 17, 2005
Organization subpart
Yes
Parent organization
COLLOM AND CARNEY CLINICAs reported in NPPES

NPPES NPI Registry

Updated by the provider on Feb 24, 2023

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

Authorized official

Name
Mary E Dwight II, CCS-P, MHA, CMPE
Title
Chief Operating Officer
Phone
(903) 614-3282

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Dermatology PhysicianGroup: 193400000X SINGLE SPECIALTY GROUP 207N00000X TX Primary

Addresses

Primary practice location

5002 Cowhorn Creek Rd
Texarkana, TX 75503

Mailing address

5002 Cowhorn Creek Rd
Texarkana, TX 75503
Phone (903) 614-3000

Other identifiers 2

IdentifierTypeStateIssuer
CU0435OtherTXRAILROAD MEDICARE
080865101MedicaidTX

Other names 1

  • Collom and Carney Clinic Dermatology Other name

Medicare participation

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

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20031226000046 TX Part B Supplier - Clinic/Group Practice 1355249541 Receives reassigned benefits from 48 practitioners
20 other NPIs on this enrollment
This NPI is an additional NPI on the enrollment
Practice locations: Texarkana, TX; Atlanta, TX; New Boston, TX

Other NPIs on the same Medicare enrollment 20

NPIs listed together on one Medicare enrollment, typically parts of the same organization.

View all 20

National Provider Directory

National Provider Directory
Part of
Nashville Dialysis Unit

Ownership & related parties

Parent organization (reported in NPPES) 1

This organization reports itself as a subpart in NPPES; the parent’s legal name matches this organization in the same state.

Practitioners & affiliated clinicians

Practitioners 3

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": "1132185600000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1677196800000",
    "number": "1891777611",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "5002 COWHORN CREEK RD",
            "city": "TEXARKANA",
            "state": "TX",
            "postal_code": "75503",
            "telephone_number": "903-614-3000",
            "fax_number": "903-614-3525"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "5002 COWHORN CREEK RD",
            "city": "TEXARKANA",
            "state": "TX",
            "postal_code": "75503",
            "telephone_number": "903-614-3000",
            "fax_number": "903-614-3525"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "COLLOM AND CARNEY CLINIC ASSOCIATION",
        "organizational_subpart": "YES",
        "parent_organization_legal_business_name": "COLLOM AND CARNEY CLINIC",
        "enumeration_date": "2005-11-17",
        "last_updated": "2023-02-24",
        "certification_date": "2023-02-24",
        "status": "A",
        "authorized_official_last_name": "DWIGHT",
        "authorized_official_first_name": "MARY",
        "authorized_official_middle_name": "E",
        "authorized_official_title_or_position": "CHIEF OPERATING OFFICER",
        "authorized_official_telephone_number": "903-614-3282",
        "authorized_official_name_suffix": "II",
        "authorized_official_credential": "CCS-P, MHA, CMPE"
    },
    "taxonomies": [
        {
            "code": "207N00000X",
            "taxonomy_group": "193400000X SINGLE SPECIALTY  GROUP",
            "desc": "Dermatology",
            "state": "TX",
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "RAILROAD MEDICARE",
            "identifier": "CU0435",
            "state": "TX"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "080865101",
            "state": "TX"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Collom and Carney Clinic Dermatology",
            "code": "5",
            "type": "Other Name"
        },
        {
            "organization_name": "Collom and Carney Clinic Dermatology",
            "code": "5",
            "type": "Other Name"
        }
    ]
}

Other providers in Texarkana, TX

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Feb 24, 2023; 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.