Provider Demographics
NPI:1033167234
Name:MEDICAL CLINIC OF NORTH TEXAS, PLLC
Entity type:Organization
Organization Name:MEDICAL CLINIC OF NORTH TEXAS, PLLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT PPM
Authorized Official - Prefix:MR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:W
Authorized Official - Last Name:BUKOSKY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:972-847-0712
Mailing Address - Street 1:PO BOX 678095
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75267-8095
Mailing Address - Country:US
Mailing Address - Phone:972-847-0712
Mailing Address - Fax:817-514-5246
Practice Address - Street 1:811 W. I-20
Practice Address - Street 2:SUITE 120
Practice Address - City:ARLINGTON
Practice Address - State:TX
Practice Address - Zip Code:76017-2694
Practice Address - Country:US
Practice Address - Phone:972-847-0712
Practice Address - Fax:817-419-4605
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-04
Last Update Date:2016-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
207Q00000X, 207RR0500X, 207V00000X, 208000000X, 2080A0000X, 2084N0400X, 208800000X, 332B00000X, 363A00000X, 363L00000X, 207R00000X
TX0926213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207RR0500XAllopathic & Osteopathic PhysiciansInternal MedicineRheumatologyGroup - Multi-Specialty
No207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Multi-Specialty
No208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
No2080A0000XAllopathic & Osteopathic PhysiciansPediatricsAdolescent MedicineGroup - Multi-Specialty
No2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurologyGroup - Multi-Specialty
No208800000XAllopathic & Osteopathic PhysiciansUrologyGroup - Multi-Specialty
No213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Multi-Specialty
No332B00000XSuppliersDurable Medical Equipment & Medical SuppliesGroup - Multi-Specialty
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Multi-Specialty
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXCU0775OtherMEDICARE RAILROAD GROUP
TXCD2314OtherMEDICARE RAILROAD GROUP
TXCG2930OtherMEDICARE RAILROAD GROUP
TX00R86COtherMEDICARE GROUP NUMBER
TXCC7989OtherMEDICARE RAILROAD GROUP
TX084933301OtherMEDICAID GROUP NUMBER
TX00R86COtherMEDICARE GROUP NUMBER
TX084933301OtherMEDICAID GROUP NUMBER
TXCU0775OtherMEDICARE RAILROAD GROUP
TXCD2314OtherMEDICARE RAILROAD GROUP