Provider Demographics
NPI:1215942073
Name:SUDAN MEDICAL CLINIC, LLC
Entity type:Organization
Organization Name:SUDAN MEDICAL CLINIC, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:LEE
Authorized Official - Last Name:MCCLANAHAN
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:806-227-2292
Mailing Address - Street 1:PO BOX 119
Mailing Address - Street 2:
Mailing Address - City:SUDAN
Mailing Address - State:TX
Mailing Address - Zip Code:79371-0119
Mailing Address - Country:US
Mailing Address - Phone:806-227-2292
Mailing Address - Fax:806-227-2293
Practice Address - Street 1:408 E US HWY 84
Practice Address - Street 2:
Practice Address - City:SUDAN
Practice Address - State:TX
Practice Address - Zip Code:79371
Practice Address - Country:US
Practice Address - Phone:806-227-2292
Practice Address - Fax:806-227-2293
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-30
Last Update Date:2021-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXH4531207Q00000X
261QR1300X
TXPA02006363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Single Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
No261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural HealthGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX118927111OtherFIRST CARE
00963ZOtherMEDICARE
TX137527OtherSUPERIOR HEALTH PLAN
TX178241901Medicaid
TX178241902Medicaid
TX0074NHOtherBLUE CROSS BLUE SHIELD
TX673950OtherMEDICARE
TX673951OtherMEDICARE
TX5594300001OtherPALMETTO GBA