Provider Demographics
NPI:1063818219
Name:COMMUNITYMED PCP
Entity type:Organization
Organization Name:COMMUNITYMED PCP
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CHIEF ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:BIRKEN
Authorized Official - Middle Name:
Authorized Official - Last Name:OLSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:972-523-4973
Mailing Address - Street 1:16775 ADDISON RD STE 200
Mailing Address - Street 2:
Mailing Address - City:ADDISON
Mailing Address - State:TX
Mailing Address - Zip Code:75001-5654
Mailing Address - Country:US
Mailing Address - Phone:972-523-4973
Mailing Address - Fax:
Practice Address - Street 1:3106 MCKINNEY ST
Practice Address - Street 2:SUITE 100
Practice Address - City:MELISSA
Practice Address - State:TX
Practice Address - Zip Code:75454-9742
Practice Address - Country:US
Practice Address - Phone:972-464-1611
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-11-17
Last Update Date:2021-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care