MEDICARE: MOLINA MEDICAL MANAGEMENT GROUP.LTD

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	208D00000X	General Practice Physician		TX

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	0052EM	OTHER	TX	BCBS
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
3	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1558323857
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MOLINA MEDICAL MANAGEMENT GROUP.LTD

Provider Business Mailing Address
First Line	:	1901 W IRVING BLVD
Second Line	:	STE 100
City	:	IRVING
State	:	TX
Zip	:	75061-6823
Country	:	US
Telephone Number	:	972-259-6900
Fax Number	:	972-254-5501

Provider Business Practice Location Address
First Line	:	1901 W IRVING BLVD
Second Line	:	SUITE 100
City	:	IRVING
State	:	TX
Zip	:	75061-6823
Country	:	US
Telephone Number	:	972-259-6900
Fax Number	:	972-254-5501

Authorized Official
Title or Position	:	ADMINISTRATOR
Name	:	MRS. BRANDI MICHELE GIBSON
Credential	:
Telephone Number	:	972-259-6900

Provider Enumeration Date	:	04/04/2006
Last Update Date	:	07/21/2022

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