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2801 Gateway Drive Suite 100 Irving TX 75063-2694 | |
| (972) 847-0712 | |
| (817) 419-4605 |
| Full Name | |
|---|---|
| Speciality | Family Medicine |
| Location | 2801 Gateway Drive, Irving, Texas |
| Authorized Official Name and Position | Michael W Bukosky (PRESIDENT PPM) |
| Authorized Official Contact | 9728470712 |
| Accepts Medicare Insurance | This clinic does not participate in Medicare Program. |
| Mailing Address | Practice Location Address |
|---|---|
Po Box 678095 Dallas TX 75267-8095 Ph: (972) 847-0712 | 2801 Gateway Drive Suite 100 Irving TX 75063-2694 Ph: (972) 847-0712 |
| NPI Number | 1598841793 |
|---|---|
| Provider Enumeration Date | 10/31/2006 |
| Last Update Date | 06/21/2018 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1598841793 | NPI | - | NPPES |
| 314801701 | Medicaid | TX | |
| 00U61E | Other | TX | MEDICARE - OTHER |
| 0043AU | Other | TX | MEDICARE - DALLAS |
| 314681301 | Medicaid | TX | |
| 00R86C | Other | TX | MEDICARE - TARRANT |
| 313447001 | Medicaid | TX |
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