# SOUTH POLK MEDICAL CLINIC LLC

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- **Entity:** Organization
- **Status:** Active
- **Organization subpart:** No

## Provider details

- **NPI number:** 1043351760
- **Authorized official:** MR. EL GRECO ROBERTS (VICE PRESIDENT OF BUSINESS AFFAIRS)
- **Authorized official phone:** (214) 372-1051

## Contact information

- **Practice address:** 3436 S POLK ST, DALLAS, TX 75224-3804
- **Practice address phone:** (214) 372-1051
- **Practice address fax:** (214) 372-9201
- **Mailing address:** 3436 S POLK ST, DALLAS, TX 75224-3804
- **Mailing address phone:** (214) 372-1051
- **Mailing address fax:** (214) 372-9201

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 363L00000X | Nurse Practitioner | 578285 | TX | Yes |

## Other

- **Enumeration date:** 02/08/2007
- **Last updated:** 07/26/2011

## 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 |