1881686343 NPI number — DR. KATHLEEN SHADLE MD

Table of content: DR. KATHLEEN SHADLE MD (NPI 1881686343)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1881686343 NPI number — DR. KATHLEEN SHADLE MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SHADLE
Provider First Name:
KATHLEEN
Provider Middle Name:
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
F

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:
1881686343
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
6565 FANNIN ST
Provider Second Line Business Mailing Address:
SUITE AX121B
Provider Business Mailing Address City Name:
HOUSTON
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
77030-2703
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
713-441-4800
Provider Business Mailing Address Fax Number:
713-793-1300

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
6565 FANNIN ST
Provider Second Line Business Practice Location Address:
SUITE AX121B
Provider Business Practice Location Address City Name:
HOUSTON
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
77030-2703
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
713-441-4800
Provider Business Practice Location Address Fax Number:
713-793-1300
Provider Enumeration Date:
08/19/2005

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 2085R0001X , with the licence number:  J1038 , 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: 129641008 . This is a "MEDICAID CSHCN" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 129641010 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: P00747796 . This is a "RR MEDICARE" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 129641007 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 129641009 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 8BN489 . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 129641001 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 85471R . This is a "BLUE CROSS" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 8FU326 . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 129641006 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".




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