1215942073 NPI number — SUDAN MEDICAL CLINIC, LLC

Table of content: (NPI 1215942073)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1215942073 NPI number — SUDAN MEDICAL CLINIC, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SUDAN 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:
1215942073
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/12/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 119
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SUDAN
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
79371-0119
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
806-227-2292
Provider Business Mailing Address Fax Number:
806-227-2293

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
408 E US HWY 84
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SUDAN
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
79371
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
806-227-2292
Provider Business Practice Location Address Fax Number:
806-227-2293
Provider Enumeration Date:
07/30/2006

Additional Information

Authorized Official

Authorized Official Last Name:
MCCLANAHAN
Authorized Official First Name:
MARK
Authorized Official Middle Name:
LEE
Authorized Official Title or Position:
PRESIDENT/PHYSICIAN
Authorized Official Telephone Number:
806-227-2292

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , with the licence number:  H4531 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 261QR1300X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363A00000X , with the licence number: PA02006 , 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: 118927111 . This is a "FIRST CARE" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 00963Z . This is a "MEDICARE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 137527 . This is a "SUPERIOR HEALTH PLAN" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 178241901 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 178241902 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 0074NH . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 673950 . This is a "MEDICARE" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 673951 . This is a "MEDICARE" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 5594300001 . This is a "PALMETTO GBA" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".




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