Provider Demographics
NPI:1538117742
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 1:6750 N. MACARTHUR BLVD
Practice Address - Street 2:SUITE 350
Practice Address - City:IRVING
Practice Address - State:TX
Practice Address - Zip Code:75039-2694
Practice Address - Country:US
Practice Address - Phone:972-847-0712
Practice Address - Fax:817-419-4605
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MEDICAL CLINIC OF NORTH TEXAS, PLLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-05-04
Last Update Date:2016-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & MetabolismGroup - Multi-Specialty
No207RR0500XAllopathic & Osteopathic PhysiciansInternal MedicineRheumatologyGroup - Multi-Specialty
No207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Multi-Specialty
No208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
No2080A0000XAllopathic & Osteopathic PhysiciansPediatricsAdolescent MedicineGroup - Multi-Specialty
No208800000XAllopathic & Osteopathic PhysiciansUrologyGroup - Multi-Specialty
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Multi-Specialty
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX112874604OtherMEDICAID GROUP NUMBER
TXCD2314OtherRAILROAD MEDICARE GROUP
TXCD3984OtherRAILROAD MEDICARE GROUP
TX0043AUOtherMEDICAID DALLAS GROUP
TXCD2315OtherRAILROAD MEDICARE GROUP
TXCD2315Medicare PIN
TX0043AUOtherMEDICAID DALLAS GROUP
TXCD2314OtherRAILROAD MEDICARE GROUP
TX0043AUMedicare PIN