Provider Demographics
NPI:1043351760
Name:SOUTH POLK MEDICAL CLINIC LLC
Entity Type:Organization
Organization Name:SOUTH POLK MEDICAL CLINIC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT OF BUSINESS AFFAIRS
Authorized Official - Prefix:MR
Authorized Official - First Name:EL GRECO
Authorized Official - Middle Name:
Authorized Official - Last Name:ROBERTS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:214-372-1051
Mailing Address - Street 1:3436 S POLK ST
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75224-3804
Mailing Address - Country:US
Mailing Address - Phone:214-372-1051
Mailing Address - Fax:214-372-9201
Practice Address - Street 1:3436 S POLK ST
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75224-3804
Practice Address - Country:US
Practice Address - Phone:214-372-1051
Practice Address - Fax:214-372-9201
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-08
Last Update Date:2011-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX578285363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX155741503Medicaid
TX190227201Medicaid
TX0041PNOtherBLUE CROSS BLUE SHIELD OF TEXAS
TX7149594OtherAETNA
TX155741504Medicaid
TX4567567OtherCIGNA
TX190227202Medicaid
TX10008701OtherAMERIGROUP
TX562313709OtherOLD TAX ID
TXNP7128OtherBLUE CROSS BLUE SHIELD
TXNP7128OtherBLUE CROSS BLUE SHIELD
TX190227202Medicaid