Provider Demographics
NPI:1265519623
Name:GRAND MEDICAL CLINIC
Entity type:Organization
Organization Name:GRAND MEDICAL CLINIC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:FAMILY NURSE PRACTITIONER OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:SUSAN
Authorized Official - Middle Name:A
Authorized Official - Last Name:BALTZ
Authorized Official - Suffix:
Authorized Official - Credentials:FAMILY NURSE PRACTIT
Authorized Official - Phone:806-374-1919
Mailing Address - Street 1:1416 S HAYDEN ST
Mailing Address - Street 2:
Mailing Address - City:AMARILLO
Mailing Address - State:TX
Mailing Address - Zip Code:79102-1635
Mailing Address - Country:US
Mailing Address - Phone:806-374-1919
Mailing Address - Fax:806-379-9213
Practice Address - Street 1:1416 S HAYDEN ST
Practice Address - Street 2:
Practice Address - City:AMARILLO
Practice Address - State:TX
Practice Address - Zip Code:79102-1635
Practice Address - Country:US
Practice Address - Phone:806-374-1919
Practice Address - Fax:806-379-9213
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-01
Last Update Date:2009-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXK2883207Q00000X
TX251159363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX092282501Medicaid
TX8P0790OtherBLUE CROSS
TX092280502OtherNHIC
G70400Medicare UPIN
TX092282501Medicaid
TX00630KMedicare Oscar/Certification