1932328986 NPI number — ISLAND HEALTH CENTER, P.A.

Table of content: (NPI 1932328986)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1932328986 NPI number — ISLAND HEALTH CENTER, P.A.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ISLAND HEALTH CENTER, P.A.
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:
1932328986
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:
4623 FORT CROCKETT BLVD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
GALVESTON
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
77551-5962
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
409-762-7646
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4623 FORT CROCKETT BLVD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
GALVESTON
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
77551-5962
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
409-762-7646
Provider Business Practice Location Address Fax Number:
409-762-9223
Provider Enumeration Date:
04/25/2007

Additional Information

Authorized Official

Authorized Official Last Name:
ANTMAN
Authorized Official First Name:
LORI
Authorized Official Middle Name:
L
Authorized Official Title or Position:
REGISTERED AGENT
Authorized Official Telephone Number:
409-762-7646

Provider Taxonomy Codes

  • Taxonomy code: 111NR0400X , with the licence number:  DC4392 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "X" .
  • Taxonomy code: 261QX0100X , with the licence number: K6521 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "X" .

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

  • Identifier: DC4392 . This is a "LICENSE" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 8H8092 . This is a "BLUE CROSS BLUESHIELD" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 1629102231 . This is a "NPI 1" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 8H8091 . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: K6521 . This is a "LICENSE" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".




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