Provider Demographics
NPI:1871774786
Name:RICHARDSON PRIMARYCARE CLINIC LLC
Entity type:Organization
Organization Name:RICHARDSON PRIMARYCARE CLINIC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MOHAMMAD
Authorized Official - Middle Name:
Authorized Official - Last Name:AMIR
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:972-437-9210
Mailing Address - Street 1:2821 E PRESIDENT GEORGE BUSH HWY
Mailing Address - Street 2:SUITE 301
Mailing Address - City:RICHARDSON
Mailing Address - State:TX
Mailing Address - Zip Code:75082-4266
Mailing Address - Country:US
Mailing Address - Phone:972-437-9210
Mailing Address - Fax:972-437-9240
Practice Address - Street 1:2821 E PRESIDENT GEORGE BUSH HWY
Practice Address - Street 2:SUITE 301
Practice Address - City:RICHARDSON
Practice Address - State:TX
Practice Address - Zip Code:75082-4266
Practice Address - Country:US
Practice Address - Phone:972-437-9210
Practice Address - Fax:972-437-9240
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-19
Last Update Date:2014-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXK0604207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX0008MAOtherBLUE CROSS BLUE SHIELD
TX170187201Medicaid
TX170187201Medicaid