1770635864 NPI number — BAYLOR COLLEGE OF MEDICINE, MEDICAL GENETICS LABS

Table of content: (NPI 1770635864)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1770635864 NPI number — BAYLOR COLLEGE OF MEDICINE, MEDICAL GENETICS LABS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BAYLOR COLLEGE OF MEDICINE, MEDICAL GENETICS LABS
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:
BAYLOR GENETICS
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:
1770635864
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/10/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 4832
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:
77210-4832
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
713-798-3295
Provider Business Mailing Address Fax Number:
713-798-4187

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1 BAYLOR PLZ
Provider Second Line Business Practice Location Address:
MS: NAB 2015, ROOM 0280C
Provider Business Practice Location Address City Name:
HOUSTON
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
77030-3411
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
713-798-3295
Provider Business Practice Location Address Fax Number:
713-798-4187
Provider Enumeration Date:
01/17/2007

Additional Information

Authorized Official

Authorized Official Last Name:
ENG
Authorized Official First Name:
CHRISTINE
Authorized Official Middle Name:
M
Authorized Official Title or Position:
EXECUTIVE LABORATORY DIRECTOR
Authorized Official Telephone Number:
713-798-6555

Provider Taxonomy Codes

  • Taxonomy code: 291U00000X , 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: 45D0660090 . This is a "CLIA" identifier . This identifiers is of the category "OTHER".
  • Identifier: 0000CL0582 . This is a "BLUE CROSS BLUE SHIELD" identifier . This identifiers is of the category "OTHER".
  • Identifier: 21093-14 . This is a "CAP" identifier . This identifiers is of the category "OTHER".
  • Identifier: 2821183 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 017730700 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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