Provider Demographics
NPI:1558323857
Name:MOLINA MEDICAL MANAGEMENT GROUP.LTD
Entity Type:Organization
Organization Name:MOLINA MEDICAL MANAGEMENT GROUP.LTD
Other - Org Name:MOLINA MEDICAL CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:BRANDI
Authorized Official - Middle Name:MICHELE
Authorized Official - Last Name:GIBSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:972-259-6900
Mailing Address - Street 1:1901 W IRVING BLVD
Mailing Address - Street 2:STE 100
Mailing Address - City:IRVING
Mailing Address - State:TX
Mailing Address - Zip Code:75061-6823
Mailing Address - Country:US
Mailing Address - Phone:972-259-6900
Mailing Address - Fax:972-254-5501
Practice Address - Street 1:1901 W IRVING BLVD
Practice Address - Street 2:SUITE 100
Practice Address - City:IRVING
Practice Address - State:TX
Practice Address - Zip Code:75061-6823
Practice Address - Country:US
Practice Address - Phone:972-259-6900
Practice Address - Fax:972-254-5501
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-04
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX0052EMOtherBCBS
TX092356702Medicaid
TX092357601Medicaid
TX092356702Medicaid