| Clinic At Cc Young | |
|
4847 W Lawther Dr Ste 100 Dallas TX 75214-1853 | |
| (214) 827-8080 | |
| Not Available |
| Full Name | Clinic At Cc Young |
|---|---|
| Speciality | Family Medicine |
| Location | 4847 W Lawther Dr, Dallas, Texas |
| Authorized Official Name and Position | Russel Crews (CEO) |
| Authorized Official Contact | 2148278080 |
| Accepts Medicare Insurance | Yes. This clinic participates in medicare program and accept medicare insurance. |
| Mailing Address | Practice Location Address |
|---|---|
| Clinic At Cc Young 4847 W Lawther Dr Ste 100 Dallas TX 75214-1853 Ph: (214) 827-8080 | Clinic At Cc Young 4847 W Lawther Dr Ste 100 Dallas TX 75214-1853 Ph: (214) 827-8080 |
| NPI Number | 1659821809 |
|---|---|
| Provider Enumeration Date | 10/12/2016 |
| Last Update Date | 11/08/2016 |
| Medicare PECOS PAC ID | 2668753401 |
|---|---|
| Medicare Enrollment ID | O20170110001068 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1659821809 | NPI | - | NPPES |
| Taxonomy | Type | License (State) | Status |
|---|---|---|---|
| 207QG0300X | Family Medicine - Geriatric Medicine | (* (Not Available)) | Primary |
| Provider Name | Tara C Goodwin |
|---|---|
| Provider Type | Practitioner - Internal Medicine |
| Provider Identifiers | NPI Number: 1306860366 PECOS PAC ID: 3779567649 Enrollment ID: I20040617000316 |
| Provider Name | Paula G Gillman |
|---|---|
| Provider Type | Practitioner - Nurse Practitioner |
| Provider Identifiers | NPI Number: 1588770804 PECOS PAC ID: 4981640141 Enrollment ID: I20050628001427 |
| Provider Name | Grady G Goodwin |
|---|---|
| Provider Type | Practitioner - Internal Medicine |
| Provider Identifiers | NPI Number: 1407964158 PECOS PAC ID: 2961403803 Enrollment ID: I20070120000029 |
| Provider Name | Laura C Demoya Vega |
|---|---|
| Provider Type | Practitioner - Internal Medicine |
| Provider Identifiers | NPI Number: 1497863187 PECOS PAC ID: 4385645795 Enrollment ID: I20070129000288 |
| Provider Name | Audrey Roodhuyzen |
|---|---|
| Provider Type | Practitioner - Nurse Practitioner |
| Provider Identifiers | NPI Number: 1861818098 PECOS PAC ID: 2365665064 Enrollment ID: I20140528000511 |
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