1013303858 NPI number — PRIME RHEUMATOLOGY CLINIC OF HOUSTON PLLC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1013303858 NPI number — PRIME RHEUMATOLOGY CLINIC OF HOUSTON PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PRIME RHEUMATOLOGY CLINIC OF HOUSTON PLLC
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:
1013303858
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/22/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
17191 ST LUKES WAY
Provider Second Line Business Mailing Address:
STE 220
Provider Business Mailing Address City Name:
THE WOODLANDS
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
77384-8042
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
832-821-5550
Provider Business Mailing Address Fax Number:
936-207-4109

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
17191 ST LUKES WAY
Provider Second Line Business Practice Location Address:
STE 220
Provider Business Practice Location Address City Name:
THE WOODLANDS
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
77384-8042
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
832-821-5550
Provider Business Practice Location Address Fax Number:
936-207-4109
Provider Enumeration Date:
04/08/2015

Additional Information

Authorized Official

Authorized Official Last Name:
MENGA
Authorized Official First Name:
GWENDOLINE
Authorized Official Middle Name:
Authorized Official Title or Position:
SOLE MBR
Authorized Official Telephone Number:
832-821-5550

Provider Taxonomy Codes

  • Taxonomy code: 207RR0500X , with the licence number:  N8040 , 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: DV7370 . This is a "RR MEDICARE" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".




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