Country Club Medical Center LLC

Primary specialty

Internal Medicine PhysicianTaxonomy code 207R00000X

License

J0549 Issued in TX

Legal business name

COUNTRY CLUB MEDICAL CENTER LLC

Practice address

8041 N Mesa St
Suite B-2
El Paso, TX 79932-1735

Phone

(915) 474-2454

Fax

(915) 222-8895

NPI assigned

Oct 4, 2014

Organization subpart

No

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name

Tracy Edward Short, PA-C

Title

Owner

Phone

(915) 474-2454

Specialties & licenses 1

Addresses

Other identifiers 4

Medicare fee-for-service enrollment

Enrolled in TX

Enrollment records 1

Practitioners 4

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles.

• Gary D Kavonian, MD

  • Emergency Medicine Physician
  • El Paso, TX
  • NPI 1558321331
  Medicare reassignment
• John Edward Short, PA-C

  • Physician Assistant
  • El Paso, TX
  • NPI 1700935277
  Medicare reassignment
• Tracy A. Short, PA

  • Endocrinology, Diabetes & Metabolism Physician
  • El Paso, TX
  • NPI 1316957178
  Medicare reassignment
• Wilbur J Strader, M.D.

  • Endocrinology, Diabetes & Metabolism Physician
  • El Paso, TX
  • NPI 1740283043
  Medicare reassignment

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1412380800000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1418342400000",
    "number": "1508269523",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "8041 N MESA ST",
            "address_2": "SUITE B-2",
            "city": "EL PASO",
            "state": "TX",
            "postal_code": "799321735",
            "telephone_number": "915-474-2454",
            "fax_number": "915-222-8895"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "8041 N MESA ST",
            "address_2": "SUITE B-2",
            "city": "EL PASO",
            "state": "TX",
            "postal_code": "799321735",
            "telephone_number": "915-474-2454",
            "fax_number": "915-222-8895"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "COUNTRY CLUB MEDICAL CENTER LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2014-10-04",
        "last_updated": "2014-12-12",
        "status": "A",
        "authorized_official_last_name": "SHORT",
        "authorized_official_first_name": "TRACY",
        "authorized_official_middle_name": "EDWARD",
        "authorized_official_title_or_position": "OWNER",
        "authorized_official_telephone_number": "915-474-2454",
        "authorized_official_credential": "PA-C"
    },
    "taxonomies": [
        {
            "code": "207R00000X",
            "taxonomy_group": "193400000X SINGLE SPECIALTY  GROUP",
            "desc": "Internal Medicine",
            "state": "TX",
            "license": "J0549",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "00825875",
            "state": "NM"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "218658701",
            "state": "TX"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "40379761",
            "state": "NM"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "MEDICARE ID - TYPE UNSPECIFIED",
            "identifier": "8A3569",
            "state": "TX"
        }
    ],
    "endpoints": [],
    "other_names": []
}

• Patrick Cotton
• Randy D Cottrell, OT
• Sylvia A Coulehan, N.P
• Counseling of El Paso, PLLC
• Counseling Specialty Group
• Country Club Urgent Care Center LLC
• Marygrace Estrella Courreges, ACNP-BC
• Courtney G. Brown, M.D., P.a.
• Cynthia Ardis Courtney, AUD., CCC-A
• Luz Maria Couttolenc

• Internal Medicine Physician in El Paso, TX
• Providers in El Paso, TX by specialty
• Internal Medicine Physician in Texas

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Dec 12, 2014; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.