Provider Demographics
NPI:1902025455
Name:INTERNAL MEDICINE CLINIC OF GRAPEVINE, PA
Entity Type:Organization
Organization Name:INTERNAL MEDICINE CLINIC OF GRAPEVINE, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:ANGIE
Authorized Official - Middle Name:
Authorized Official - Last Name:LOWE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:817-481-1511
Mailing Address - Street 1:1600 W COLLEGE ST
Mailing Address - Street 2:#490
Mailing Address - City:GRAPEVINE
Mailing Address - State:TX
Mailing Address - Zip Code:76051-3580
Mailing Address - Country:US
Mailing Address - Phone:817-481-1511
Mailing Address - Fax:
Practice Address - Street 1:1600 W COLLEGE ST
Practice Address - Street 2:#490
Practice Address - City:GRAPEVINE
Practice Address - State:TX
Practice Address - Zip Code:76051-3580
Practice Address - Country:US
Practice Address - Phone:817-481-1511
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-24
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care