Provider Demographics
NPI:1437106945
Name:BUCKNER FAMILY MEDICAL ASSOCIATION, PA
Entity Type:Organization
Organization Name:BUCKNER FAMILY MEDICAL ASSOCIATION, PA
Other - Org Name:PATIENTS CHOICE FAMILY MEDICINE AND REHAB
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CREDENTIALING SPECIALIST
Authorized Official - Prefix:
Authorized Official - First Name:MICHELE
Authorized Official - Middle Name:C
Authorized Official - Last Name:GRAHAM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:972-245-1315
Mailing Address - Street 1:4801 S BUCKNER BLVD
Mailing Address - Street 2:SUITE 200
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75227-2304
Mailing Address - Country:US
Mailing Address - Phone:214-381-7700
Mailing Address - Fax:214-381-7702
Practice Address - Street 1:4801 S BUCKNER BLVD
Practice Address - Street 2:SUITE 200
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75227-2304
Practice Address - Country:US
Practice Address - Phone:214-381-7700
Practice Address - Fax:214-381-7702
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-28
Last Update Date:2008-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX207Q00000X, 225100000X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX00748WMedicare ID - Type Unspecified