1043351760 NPI number — SOUTH POLK MEDICAL CLINIC LLC

Table of content: (NPI 1043351760)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1043351760 NPI number — SOUTH POLK MEDICAL CLINIC LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SOUTH POLK MEDICAL CLINIC LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1043351760
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/26/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3436 S POLK ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DALLAS
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
75224-3804
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
214-372-1051
Provider Business Mailing Address Fax Number:
214-372-9201

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3436 S POLK ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
DALLAS
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
75224-3804
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
214-372-1051
Provider Business Practice Location Address Fax Number:
214-372-9201
Provider Enumeration Date:
02/08/2007

Additional Information

Authorized Official

Authorized Official Last Name:
ROBERTS
Authorized Official First Name:
EL GRECO
Authorized Official Middle Name:
Authorized Official Title or Position:
VICE PRESIDENT OF BUSINESS AFFAIRS
Authorized Official Telephone Number:
214-372-1051

Provider Taxonomy Codes

  • Taxonomy code: 363L00000X , with the licence number:  578285 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 155741503 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 190227201 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 0041PN . This is a "BLUE CROSS BLUE SHIELD OF TEXAS" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 7149594 . This is a "AETNA" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 155741504 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 4567567 . This is a "CIGNA" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 190227202 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 10008701 . This is a "AMERIGROUP" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 562313709 . This is a "OLD TAX ID" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: NP7128 . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".




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