Organization
COUNTRY CLUB MEDICAL CENTER LLC
Active
Organization
COUNTRY CLUB MEDICAL CENTER LLC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
TRACY EDWARD SHORT PA-C (OWNER)
(915) 474-2454
Entity
Organization
Contact information
Practice address
8041 N MESA ST, SUITE B-2, EL PASO, TX 79932-1735
(915) 474-2454
(915) 222-8895
Mailing address
8041 N MESA ST, SUITE B-2, EL PASO, TX 79932-1735
(915) 474-2454
(915) 222-8895
Taxonomy
Speciality
Code
Description
License number
State
207R00000X
Internal Medicine Physician
Primary
J0549
TX
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
00825875
—
NM
05
—
218658701
—
TX
05
—
40379761
—
NM
01
—
8A3569
MEDICARE ID - TYPE UNSPECIFIED
TX
Enumeration date
10/04/2014
Last updated
12/12/2014
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