1922544592 NPI number — MEDINA PRIMARY CARE PLLC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1922544592 NPI number — MEDINA PRIMARY CARE PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MEDINA PRIMARY CARE PLLC
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:
6
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:
1922544592
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/30/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4013 14TH ST
Provider Second Line Business Mailing Address:
401
Provider Business Mailing Address City Name:
PLANO
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
75074-7125
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
972-456-9292
Provider Business Mailing Address Fax Number:
972-456-9393

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4013 14TH ST
Provider Second Line Business Practice Location Address:
401
Provider Business Practice Location Address City Name:
PLANO
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
75074-7125
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
972-456-9292
Provider Business Practice Location Address Fax Number:
972-456-9393
Provider Enumeration Date:
01/06/2017

Additional Information

Authorized Official

Authorized Official Last Name:
ALI
Authorized Official First Name:
MIR
Authorized Official Middle Name:
MAJID
Authorized Official Title or Position:
PHYSICAN OWNER
Authorized Official Telephone Number:
972-456-9292

Provider Taxonomy Codes

  • Taxonomy code: 261Q00000X , with the licence number:  Q6929 , 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: 368903601 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2025 www.npivalidator.com