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Organization
SOUTH POLK MEDICAL CLINIC LLC
Active
Organization
SOUTH POLK MEDICAL CLINIC LLC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
MR. EL GRECO ROBERTS (VICE PRESIDENT OF BUSINESS AFFAIRS)
(214) 372-1051
Entity
Organization
Contact information
Practice address
3436 S POLK ST, DALLAS, TX 75224-3804
(214) 372-1051
(214) 372-9201
Mailing address
3436 S POLK ST, DALLAS, TX 75224-3804
(214) 372-1051
(214) 372-9201
Taxonomy
Speciality
Code
Description
License number
State
363L00000X
Nurse Practitioner
Primary
578285
TX
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
0041PN
BLUE CROSS BLUE SHIELD OF TEXAS
TX
01
—
10008701
AMERIGROUP
TX
05
—
155741503
—
TX
05
—
155741504
—
TX
05
—
190227201
—
TX
05
—
190227202
—
TX
01
—
4567567
CIGNA
TX
01
—
562313709
OLD TAX ID
TX
01
—
7149594
AETNA
TX
01
—
NP7128
BLUE CROSS BLUE SHIELD
TX
Enumeration date
02/08/2007
Last updated
07/26/2011
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