| Grace Medical Association, Pa | |
|
200 W. Southwest Pkwy Lewisville TX 75067 | |
| (972) 420-6777 | |
| (972) 420-0656 |
| Full Name | Grace Medical Association, Pa |
|---|---|
| Speciality | Internal Medicine |
| Location | 200 W. Southwest Pkwy, Lewisville, Texas |
| Authorized Official Name and Position | Smart O Idemudia (OWNER) |
| Authorized Official Contact | 9724206777 |
| Accepts Medicare Insurance | Yes. This clinic participates in medicare program and accept medicare insurance. |
| Mailing Address | Practice Location Address |
|---|---|
| Grace Medical Association, Pa Po Box 292128 Lewisville TX 75029-2128 Ph: (972) 420-6777 | Grace Medical Association, Pa 200 W. Southwest Pkwy Lewisville TX 75067 Ph: (972) 420-6777 |
| NPI Number | 1487695631 |
|---|---|
| Provider Enumeration Date | 06/09/2006 |
| Last Update Date | 06/02/2014 |
| Medicare PECOS PAC ID | 6800081738 |
|---|---|
| Medicare Enrollment ID | O20101117000455 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1487695631 | NPI | - | NPPES |
| 0078DM | Other | TX | BLUE CROSS / BLUE SHIELD |
| 138993413 | Medicaid | TX | |
| F46614 | Other | TX | COMMERCIAL |
| Taxonomy | Type | License (State) | Status |
|---|---|---|---|
| 207Q00000X | Family Medicine | J91000 (Texas) | Secondary |
| 207R00000X | Internal Medicine | J91000 (Texas) | Primary |
| Provider Name | Smart Idemudia |
|---|---|
| Provider Type | Practitioner - Internal Medicine |
| Provider Identifiers | NPI Number: 1154364974 PECOS PAC ID: 8820093230 Enrollment ID: I20060918000456 |
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