Provider Demographics
NPI:1306023049
Name:PRIMARY CARE INTERNAL MEDICINE PLLC
Entity type:Organization
Organization Name:PRIMARY CARE INTERNAL MEDICINE PLLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:SOLE OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:FREDERICK
Authorized Official - Last Name:DOERNER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:972-908-3455
Mailing Address - Street 1:1111 RAINTREE CIR
Mailing Address - Street 2:SUITE 240
Mailing Address - City:ALLEN
Mailing Address - State:TX
Mailing Address - Zip Code:75013-4901
Mailing Address - Country:US
Mailing Address - Phone:972-908-3455
Mailing Address - Fax:469-640-1978
Practice Address - Street 1:1111 RAINTREE CIR
Practice Address - Street 2:SUITE 240
Practice Address - City:ALLEN
Practice Address - State:TX
Practice Address - Zip Code:75013-4901
Practice Address - Country:US
Practice Address - Phone:972-908-3455
Practice Address - Fax:972-908-3477
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-24
Last Update Date:2017-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXL8045207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX00Z028Medicare PIN