Active NPI
South Polk Medical Clinic LLC
- Nurse Practitioner
- Dallas, TX
National Provider Identifier
1043351760
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Nurse Practitioner
- License
- 578285
- Legal business name
- SOUTH POLK MEDICAL CLINIC LLC
- Practice address
- 3436 S Polk St
Dallas, TX 75224-3804 - Phone
- (214) 372-1051
- Fax
- (214) 372-9201
- NPI assigned
- Feb 8, 2007
- Organization subpart
- No
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Authorized official
- Name
- Mr. El Greco Roberts
- Title
- Vice President of Business Affairs
- Phone
- (214) 372-1051
Specialties & licenses 1
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Nurse Practitioner | 363L00000X | 578285 | TX | Primary |
Addresses
Primary practice location
3436 S Polk St
Dallas, TX 75224-3804
Mailing address
3436 S Polk St
Dallas, TX 75224-3804
Phone (214) 372-1051
Other identifiers 10
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 155741503 | Medicaid | TX | |
| 190227201 | Medicaid | TX | |
| 0041PN | Other | TX | BLUE CROSS BLUE SHIELD OF TEXAS |
| 7149594 | Other | TX | AETNA |
| 155741504 | Medicaid | TX | |
| 4567567 | Other | TX | CIGNA |
| 190227202 | Medicaid | TX | |
| 10008701 | Other | TX | AMERIGROUP |
| 562313709 | Other | TX | OLD TAX ID |
| NP7128 | Other | TX | BLUE CROSS BLUE SHIELD |
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Enrolled in TX
Enrollment records 1
Laboratory certificates & supplier records
Derived by NPIMapThese CMS records do not include an NPI. They are shown because their name and street address match this provider’s.
CLIA laboratory certificates
| CLIA number | Laboratory | Certificate | Expires |
|---|---|---|---|
| 45D1011714 | South Polk Medical Clinic | Certificate of waiver | Apr 21, 2027 |
National Provider Directory
National Provider DirectoryLocations
3434 S Polk St
Ste A
Dallas, TX 75224
Phone (214) 372-1051
Practitioners & affiliated clinicians
Practitioners 4
Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles.
-
- Family Nurse Practitioner
- Dallas, TX
- NPI 1457845208
-
- Family Nurse Practitioner
- Dallas, TX
- NPI 1548143308
-
- Family Nurse Practitioner
- Dallas, TX
- NPI 1205782117
-
- Nurse Practitioner
- Dallas, TX
- NPI 1629093455
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1170892800000",
"enumeration_type": "NPI-2",
"last_updated_epoch": "1311638400000",
"number": "1043351760",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "3436 S POLK ST",
"city": "DALLAS",
"state": "TX",
"postal_code": "752243804",
"telephone_number": "214-372-1051",
"fax_number": "214-372-9201"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "3436 S POLK ST",
"city": "DALLAS",
"state": "TX",
"postal_code": "752243804",
"telephone_number": "214-372-1051",
"fax_number": "214-372-9201"
}
],
"practiceLocations": [],
"basic": {
"organization_name": "SOUTH POLK MEDICAL CLINIC LLC",
"organizational_subpart": "NO",
"enumeration_date": "2007-02-08",
"last_updated": "2011-07-26",
"status": "A",
"authorized_official_last_name": "ROBERTS",
"authorized_official_first_name": "EL GRECO",
"authorized_official_title_or_position": "VICE PRESIDENT OF BUSINESS AFFAIRS",
"authorized_official_telephone_number": "214-372-1051",
"authorized_official_name_prefix": "Mr."
},
"taxonomies": [
{
"code": "363L00000X",
"taxonomy_group": "193400000X SINGLE SPECIALTY GROUP",
"desc": "Nurse Practitioner",
"state": "TX",
"license": "578285",
"primary": true
}
],
"identifiers": [
{
"code": "05",
"desc": "MEDICAID",
"issuer": null,
"identifier": "155741503",
"state": "TX"
},
{
"code": "05",
"desc": "MEDICAID",
"issuer": null,
"identifier": "190227201",
"state": "TX"
},
{
"code": "01",
"desc": "Other (non-Medicare)",
"issuer": "BLUE CROSS BLUE SHIELD OF TEXAS",
"identifier": "0041PN",
"state": "TX"
},
{
"code": "01",
"desc": "Other (non-Medicare)",
"issuer": "AETNA",
"identifier": "7149594",
"state": "TX"
},
{
"code": "05",
"desc": "MEDICAID",
"issuer": null,
"identifier": "155741504",
"state": "TX"
},
{
"code": "01",
"desc": "Other (non-Medicare)",
"issuer": "CIGNA",
"identifier": "4567567",
"state": "TX"
},
{
"code": "05",
"desc": "MEDICAID",
"issuer": null,
"identifier": "190227202",
"state": "TX"
},
{
"code": "01",
"desc": "Other (non-Medicare)",
"issuer": "AMERIGROUP",
"identifier": "10008701",
"state": "TX"
},
{
"code": "01",
"desc": "Other (non-Medicare)",
"issuer": "OLD TAX ID",
"identifier": "562313709",
"state": "TX"
},
{
"code": "01",
"desc": "Other (non-Medicare)",
"issuer": "BLUE CROSS BLUE SHIELD",
"identifier": "NP7128",
"state": "TX"
}
],
"endpoints": [],
"other_names": []
}Other providers in Dallas, TX
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Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jul 26, 2011; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
- Medicare Care Compare (CMS): clinician profile, group practices, facility affiliations, MIPS scores and star ratings.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.