1750563276 NPI number — FAMILY MEDICINE CLINIC

Table of content: (NPI 1750563276)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1750563276 NPI number — FAMILY MEDICINE CLINIC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
FAMILY MEDICINE 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:
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:
1750563276
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/21/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 11220
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:
77293-1220
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
281-880-9710
Provider Business Mailing Address Fax Number:
281-880-9711

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
17203 RED OAK DR
Provider Second Line Business Practice Location Address:
SUITE 201
Provider Business Practice Location Address City Name:
HOUSTON
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
77090-2640
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
281-880-9710
Provider Business Practice Location Address Fax Number:
281-880-9711
Provider Enumeration Date:
11/27/2007

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
BORGES
Authorized Official First Name:
RAFAEL
Authorized Official Middle Name:
G
Authorized Official Title or Position:
DOCTOR
Authorized Official Telephone Number:
281-880-9710

Provider Taxonomy Codes

  • Taxonomy code: 302R00000X , with the licence number:  K9230 , 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: 042969802 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: TXB110824 . This is a "MEDICARE GROUP PTAN" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 8AJ811 . This is a "B/C B/S OF TEXAS" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".