Provider Demographics
NPI:1922544592
Name:MEDINA PRIMARY CARE PLLC
Entity Type:Organization
Organization Name:MEDINA PRIMARY CARE PLLC
Other - Org Name:MEDINA PRIMARY CARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHYSICAN OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MIR
Authorized Official - Middle Name:MAJID
Authorized Official - Last Name:ALI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:972-456-9292
Mailing Address - Street 1:4013 14TH ST
Mailing Address - Street 2:401
Mailing Address - City:PLANO
Mailing Address - State:TX
Mailing Address - Zip Code:75074-7125
Mailing Address - Country:US
Mailing Address - Phone:972-456-9292
Mailing Address - Fax:972-456-9393
Practice Address - Street 1:4013 14TH ST
Practice Address - Street 2:401
Practice Address - City:PLANO
Practice Address - State:TX
Practice Address - Zip Code:75074-7125
Practice Address - Country:US
Practice Address - Phone:972-456-9292
Practice Address - Fax:972-456-9393
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-01-06
Last Update Date:2019-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXQ6929261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX368903601Medicaid