Provider Demographics
| NPI: | 1033167234 |
|---|---|
| Name: | MEDICAL CLINIC OF NORTH TEXAS, PLLC |
| Entity Type: | Organization |
| Organization Name: | MEDICAL CLINIC OF NORTH TEXAS, PLLC |
| Other - Org Name: | USMD PHYSICIAN SERVICES |
| Other - Org Type: | Doing Business As |
| Authorized Official - Title/Position: | PRESIDENT PPM |
| Authorized Official - Prefix: | MR |
| Authorized Official - First Name: | MICHAEL |
| Authorized Official - Middle Name: | W |
| Authorized Official - Last Name: | BUKOSKY |
| Authorized Official - Suffix: | |
| Authorized Official - Credentials: | |
| Authorized Official - Phone: | 972-847-0712 |
| Mailing Address - Street 1: | PO BOX 678095 |
| Mailing Address - Street 2: | |
| Mailing Address - City: | DALLAS |
| Mailing Address - State: | TX |
| Mailing Address - Zip Code: | 75267-8095 |
| Mailing Address - Country: | US |
| Mailing Address - Phone: | 972-847-0712 |
| Mailing Address - Fax: | 817-514-5246 |
| Practice Address - Street 1: | 811 W. I-20 |
| Practice Address - Street 2: | SUITE 120 |
| Practice Address - City: | ARLINGTON |
| Practice Address - State: | TX |
| Practice Address - Zip Code: | 76017-2694 |
| Practice Address - Country: | US |
| Practice Address - Phone: | 972-847-0712 |
| Practice Address - Fax: | 817-419-4605 |
| EIN: | <UNAVAIL> |
| Is Organization Subpart?: | No |
| Parent Organization LBN: | |
| Parent Organization TIN: | |
| Enumeration Date: | 2006-05-04 |
| Last Update Date: | 2016-11-08 |
| Deactivation Date: | |
| Deactivation Code: | |
| Reactivation Date: |
Provider Licenses
| State | License ID | Taxonomies |
|---|---|---|
| 207Q00000X, 207R00000X, 207RR0500X, 207V00000X, 208000000X, 2080A0000X, 2084N0400X, 208800000X, 332B00000X, 363A00000X, 363L00000X | ||
| TX | 0926 | 213E00000X |
Provider Taxonomies
| Primary? | Code | Type | Classification | Specialization | Group |
|---|---|---|---|---|---|
| Yes | 207R00000X | Allopathic & Osteopathic Physicians | Internal Medicine | Group - Multi-Specialty | |
| No | 207Q00000X | Allopathic & Osteopathic Physicians | Family Medicine | Group - Multi-Specialty | |
| No | 207RR0500X | Allopathic & Osteopathic Physicians | Internal Medicine | Rheumatology | Group - Multi-Specialty |
| No | 207V00000X | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | Group - Multi-Specialty | |
| No | 208000000X | Allopathic & Osteopathic Physicians | Pediatrics | Group - Multi-Specialty | |
| No | 2080A0000X | Allopathic & Osteopathic Physicians | Pediatrics | Adolescent Medicine | Group - Multi-Specialty |
| No | 2084N0400X | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology | Group - Multi-Specialty |
| No | 208800000X | Allopathic & Osteopathic Physicians | Urology | Group - Multi-Specialty | |
| No | 213E00000X | Podiatric Medicine & Surgery Service Providers | Podiatrist | Group - Multi-Specialty | |
| No | 332B00000X | Suppliers | Durable Medical Equipment & Medical Supplies | Group - Multi-Specialty | |
| No | 363A00000X | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Group - Multi-Specialty | |
| No | 363L00000X | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Group - Multi-Specialty |
Provider Identifiers
| State | Identifier ID | ID Type | Issuer |
|---|---|---|---|
| TX | CU0775 | Other | MEDICARE RAILROAD GROUP |
| TX | CD2314 | Other | MEDICARE RAILROAD GROUP |
| TX | CG2930 | Other | MEDICARE RAILROAD GROUP |
| TX | 00R86C | Other | MEDICARE GROUP NUMBER |
| TX | CC7989 | Other | MEDICARE RAILROAD GROUP |
| TX | 084933301 | Other | MEDICAID GROUP NUMBER |
| TX | 00R86C | Other | MEDICARE GROUP NUMBER |
| TX | 084933301 | Other | MEDICAID GROUP NUMBER |
| TX | CU0775 | Other | MEDICARE RAILROAD GROUP |
| TX | CD2314 | Other | MEDICARE RAILROAD GROUP |
