1457385551 NPI number — EAST TEXAS EYE CENTER PA

Table of content: (NPI 1457385551)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1457385551 NPI number — EAST TEXAS EYE CENTER PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
EAST TEXAS EYE CENTER PA
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1457385551
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/05/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
18700 W LAKE HOUSTON PKWY
Provider Second Line Business Mailing Address:
STE B101
Provider Business Mailing Address City Name:
HUMBLE
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
77346-3349
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
281-812-4000
Provider Business Mailing Address Fax Number:
281-812-3331

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
901 E HOUSTON ST
Provider Second Line Business Practice Location Address:
STE B
Provider Business Practice Location Address City Name:
CLEVELAND
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
77327-4602
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
281-659-2020
Provider Business Practice Location Address Fax Number:
281-659-2030
Provider Enumeration Date:
07/11/2006

Additional Information

Authorized Official

Authorized Official Last Name:
SHRUM
Authorized Official First Name:
K
Authorized Official Middle Name:
RAY
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
281-659-2020

Provider Taxonomy Codes

  • Taxonomy code: 152W00000X , with the licence number:  02830TG , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207W00000X , with the licence number: L2649 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 918304 . This is a "BLOCK VISION" identifier . This identifiers is of the category "OTHER".
  • Identifier: 21210202328 . This is a "BEECH STREET" identifier . This identifiers is of the category "OTHER".
  • Identifier: DE8958 . This is a "MEDICARE RAILROAD" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 0084GS . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 180044544 . This is a "MEDICARE RAILROAD" identifier . This identifiers is of the category "OTHER".
  • Identifier: 7114117 . This is a "AETNA" identifier . This identifiers is of the category "OTHER".
  • Identifier: 145198102 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 975250 . This is a "ONE HEALTH PLAN" identifier . This identifiers is of the category "OTHER".
  • Identifier: 4119904 . This is a "CIGNA" identifier . This identifiers is of the category "OTHER".
  • Identifier: 5248990 . This is a "FIRST HEALTH" identifier . This identifiers is of the category "OTHER".
  • Identifier: 145198103 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 21210202328 . This is a "BEECHSTREET" identifier . This identifiers is of the category "OTHER".
  • Identifier: 5248990 . This is a "CCN" identifier . This identifiers is of the category "OTHER".




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