1093822140 NPI number — RAYMOND P MUSSETT MD PLLC

Table of content: (NPI 1093822140)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1093822140 NPI number — RAYMOND P MUSSETT MD PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
RAYMOND P MUSSETT MD 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:
ROMA MEDICAL CLINIC
Provider Other Organization Name Type Code:
3
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:
1093822140
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/02/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 1120
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ROMA
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
78584
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
956-849-2176
Provider Business Mailing Address Fax Number:
956-849-3439

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
640 E BRAVO BLVD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ROMA
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
78584
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
956-849-2176
Provider Business Practice Location Address Fax Number:
956-849-3439
Provider Enumeration Date:
08/24/2006

Additional Information

Authorized Official

Authorized Official Last Name:
MUSSETT
Authorized Official First Name:
RAYMOND
Authorized Official Middle Name:
P
Authorized Official Title or Position:
PRESIDENT/OWNER
Authorized Official Telephone Number:
956-849-2176

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , 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: 827083763 . This is a "PALMETTO MEDICARE" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 135201506 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 00734HF . This is a "BCBS" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 063426301 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".




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