1033167234 NPI number — MEDICAL CLINIC OF NORTH TEXAS, PLLC

Table of content: (NPI 1033167234)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1033167234 NPI number — MEDICAL CLINIC OF NORTH TEXAS, PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MEDICAL CLINIC OF NORTH TEXAS, 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:
1033167234
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/08/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 678095
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:
75267-8095
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
972-847-0712
Provider Business Mailing Address Fax Number:
817-514-5246

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
811 W. I-20
Provider Second Line Business Practice Location Address:
SUITE 120
Provider Business Practice Location Address City Name:
ARLINGTON
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
76017-2694
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
972-847-0712
Provider Business Practice Location Address Fax Number:
817-419-4605
Provider Enumeration Date:
05/04/2006

Additional Information

Authorized Official

Authorized Official Last Name:
BUKOSKY
Authorized Official First Name:
MICHAEL
Authorized Official Middle Name:
W
Authorized Official Title or Position:
PRESIDENT PPM
Authorized Official Telephone Number:
972-847-0712

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207R00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 207RR0500X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207V00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 208000000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2080A0000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2084N0400X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 208800000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 213E00000X , with the licence number: 0926 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 332B00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363A00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363L00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: CU0775 . This is a "MEDICARE RAILROAD GROUP" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: CD2314 . This is a "MEDICARE RAILROAD GROUP" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: CG2930 . This is a "MEDICARE RAILROAD GROUP" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 00R86C . This is a "MEDICARE GROUP NUMBER" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: CC7989 . This is a "MEDICARE RAILROAD GROUP" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 084933301 . This is a "MEDICAID GROUP NUMBER" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".




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