MEDICARE: SOUTH POLK MEDICAL CLINIC LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363L00000X	Nurse Practitioner	578285	TX

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
3	0041PN	OTHER	TX	BLUE CROSS BLUE SHIELD OF TEXAS
4	7149594	OTHER	TX	AETNA
5	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
6	4567567	OTHER	TX	CIGNA
7	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
8	10008701	OTHER	TX	AMERIGROUP
9	562313709	OTHER	TX	OLD TAX ID
10	NP7128	OTHER	TX	BLUE CROSS BLUE SHIELD

General Provider Information

NPI Number	:	1043351760
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SOUTH POLK MEDICAL CLINIC LLC

Provider Business Mailing Address
First Line	:	3436 S POLK ST
Second Line	:
City	:	DALLAS
State	:	TX
Zip	:	75224-3804
Country	:	US
Telephone Number	:	214-372-1051
Fax Number	:	214-372-9201

Provider Business Practice Location Address
First Line	:	3436 S POLK ST
Second Line	:
City	:	DALLAS
State	:	TX
Zip	:	75224-3804
Country	:	US
Telephone Number	:	214-372-1051
Fax Number	:	214-372-9201

Authorized Official
Title or Position	:	VICE PRESIDENT OF BUSINESS AFFAIRS
Name	:	MR. EL GRECO ROBERTS
Credential	:
Telephone Number	:	214-372-1051

Provider Enumeration Date	:	02/08/2007
Last Update Date	:	07/26/2011

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Directions to “SOUTH POLK MEDICAL CLINIC LLC ” Practice Location

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