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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