=====================================================
General NPI Number Information
=====================================================
NPI Number | 1083630610
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CONCORD MEDICAL GROUP PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/15/2006
-----------------------------------------------------
Last Update Date | 01/08/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1602 AVENUE Q
-----------------------------------------------------
City | LUBBOCK
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 79401-4732
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 888-264-0330
-----------------------------------------------------
Fax | 800-611-5029
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 3689 DEPARTMENT 257
-----------------------------------------------------
City | SUGAR LAND
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77487-3310
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 888-264-0330
-----------------------------------------------------
Fax | 800-611-5029
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | EVP OF OPERATIONS
-----------------------------------------------------
Name | MRS. JORDAN ANN TUCKETT
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 972-829-6610
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207P00000X
-----------------------------------------------------
Taxonomy Name | Emergency Medicine Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------