1457480212 NPI number — BAYLOR COLLEG OF MEDICINE TEEN HEALTH CLINIC

Table of content: (NPI 1457480212)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1457480212 NPI number — BAYLOR COLLEG OF MEDICINE TEEN HEALTH CLINIC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BAYLOR COLLEG OF MEDICINE TEEN HEALTH CLINIC
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:
CULLEN TEEN CLINIC
Provider Other Organization Name Type Code:
5
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:
1457480212
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1504 TAUB LOOP
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
HOUSTON
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
77030-1608
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
713-873-3601
Provider Business Mailing Address Fax Number:
713-873-3608

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5737 CULLEN BLVD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
HOUSTON
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
77021-1638
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
713-440-7313
Provider Business Practice Location Address Fax Number:
713-440-8358
Provider Enumeration Date:
03/05/2007

Additional Information

Authorized Official

Authorized Official Last Name:
SMITH
Authorized Official First Name:
PEGGY
Authorized Official Middle Name:
B.
Authorized Official Title or Position:
PROFESSOR DIRECTOR
Authorized Official Telephone Number:
713-873-3601

Provider Taxonomy Codes

  • Taxonomy code: 261QA0005X ; information, associated with the NPI states the following Primary Taxonomy Switch: "X" .
  • Taxonomy code: 261QF0050X ; information, associated with the NPI states the following Primary Taxonomy Switch: "X" .

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





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