| Medeval, Llc | |
|
4920 Elizabeth St Texarkana TX 75503-2912 | |
| (903) 792-3812 | |
| Not Available |
| Full Name | Medeval, Llc |
|---|---|
| Speciality | General Practice |
| Location | 4920 Elizabeth St, Texarkana, Texas |
| Authorized Official Name and Position | Dewitt Charles Fortenberry (MEDICAL DIRECTOR) |
| Authorized Official Contact | 3016415512 |
| Accepts Medicare Insurance | Yes. This clinic participates in medicare program and accept medicare insurance. |
| Mailing Address | Practice Location Address |
|---|---|
| Medeval, Llc 116 Westlake Rd Texarkana TX 75501-0006 Ph: (903) 293-7093 | Medeval, Llc 4920 Elizabeth St Texarkana TX 75503-2912 Ph: (903) 792-3812 |
| NPI Number | 1740548346 |
|---|---|
| Provider Enumeration Date | 05/02/2012 |
| Last Update Date | 09/17/2023 |
| Medicare PECOS PAC ID | 9537319256 |
|---|---|
| Medicare Enrollment ID | O20121015000495 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1740548346 | NPI | - | NPPES |
| Taxonomy | Type | License (State) | Status |
|---|---|---|---|
| 208D00000X | General Practice | L8691 (Texas) | Primary |
| Provider Name | Dewitt C Fortenberry |
|---|---|
| Provider Type | Practitioner - Internal Medicine |
| Provider Identifiers | NPI Number: 1114960473 PECOS PAC ID: 7315919925 Enrollment ID: I20040812000544 |
| Provider Name | Anne J Higgins |
|---|---|
| Provider Type | Practitioner - Nurse Practitioner |
| Provider Identifiers | NPI Number: 1801291901 PECOS PAC ID: 4284950825 Enrollment ID: I20150226000559 |
| Provider Name | Jenisa Jasi Johnson |
|---|---|
| Provider Type | Practitioner - Nurse Practitioner |
| Provider Identifiers | NPI Number: 1962119586 PECOS PAC ID: 8022471325 Enrollment ID: I20230905002165 |
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