| Country Club Medical Center Llc | |
|
8041 N Mesa St Suite B-2 El Paso TX 79932-1735 | |
| (915) 474-2454 | |
| (915) 222-8895 |
| Full Name | Country Club Medical Center Llc |
|---|---|
| Speciality | Internal Medicine |
| Location | 8041 N Mesa St, El Paso, Texas |
| Authorized Official Name and Position | Tracy Edward Short (OWNER) |
| Authorized Official Contact | 9154742454 |
| Accepts Medicare Insurance | Yes. This clinic participates in medicare program and accept medicare insurance. |
| Mailing Address | Practice Location Address |
|---|---|
| Country Club Medical Center Llc 8041 N Mesa St Suite B-2 El Paso TX 79932-1735 Ph: (915) 474-2454 | Country Club Medical Center Llc 8041 N Mesa St Suite B-2 El Paso TX 79932-1735 Ph: (915) 474-2454 |
| NPI Number | 1508269523 |
|---|---|
| Provider Enumeration Date | 10/04/2014 |
| Last Update Date | 12/12/2014 |
| Medicare PECOS PAC ID | 6709108103 |
|---|---|
| Medicare Enrollment ID | O20141212001178 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1508269523 | NPI | - | NPPES |
| 00825875 | Medicaid | NM | |
| 218658701 | Medicaid | TX | |
| 40379761 | Medicaid | NM | |
| 8A3569 | Other | TX | MEDICARE ID - TYPE UNSPECIFIED |
| Taxonomy | Type | License (State) | Status |
|---|---|---|---|
| 207R00000X | Internal Medicine | J0549 (Texas) | Primary |
| Provider Name | Gary D Kavonian |
|---|---|
| Provider Type | Practitioner - Internal Medicine |
| Provider Identifiers | NPI Number: 1558321331 PECOS PAC ID: 3577528934 Enrollment ID: I20041124000482 |
| Provider Name | Wilbur Jackson Strader |
|---|---|
| Provider Type | Practitioner - Internal Medicine |
| Provider Identifiers | NPI Number: 1740283043 PECOS PAC ID: 1850203621 Enrollment ID: I20101027001287 |
| Provider Name | Stephanie Lynn Hunter |
|---|---|
| Provider Type | Practitioner - Nurse Practitioner |
| Provider Identifiers | NPI Number: 1306356290 PECOS PAC ID: 7416214036 Enrollment ID: I20171206001160 |
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