Provider Demographics
NPI:1912955030
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 1:5501 INDEPENDENCE PARKWAY
Practice Address - Street 2:SUITE 110
Practice Address - City:PLANO
Practice Address - State:TX
Practice Address - Zip Code:75023-2694
Practice Address - Country:US
Practice Address - Phone:972-847-0712
Practice Address - Fax:817-419-4605
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
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
No133V00000XDietary & Nutritional Service ProvidersDietitian, RegisteredGroup - 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
TXCD2315OtherMEDICARE RAILROAD GROUP
TXCC8907OtherMEDICARE RAILROAD GROUP
TX00U61EOtherMEDICARE OTHER GROUP
TX112874603OtherMEDICAID GROUP NUMBER
TXCG7842OtherMEDICARE RAILROAD GROUP
TXCG7842Medicare PIN
TXCC8907Medicare PIN
TXCD2315OtherMEDICARE RAILROAD GROUP