1124011465 NPI number — MEDICAL CENTER EAR, NOSE AND THROAT ASSOCIATES OF HOUSTON, PLLC

Table of content: (NPI 1124011465)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1124011465 NPI number — MEDICAL CENTER EAR, NOSE AND THROAT ASSOCIATES OF HOUSTON, PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MEDICAL CENTER EAR, NOSE AND THROAT ASSOCIATES 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:
HOUSTON SINUS CENTER
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:
1124011465
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/17/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4101 GREENBRIAR ST.
Provider Second Line Business Mailing Address:
SUITE #320
Provider Business Mailing Address City Name:
HOUSTON
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
77098-5296
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
713-795-0111
Provider Business Mailing Address Fax Number:
713-795-8586

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4101 GREENBRIAR ST.
Provider Second Line Business Practice Location Address:
SUITE #320
Provider Business Practice Location Address City Name:
HOUSTON
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
77098-5296
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
713-795-0111
Provider Business Practice Location Address Fax Number:
713-490-5987
Provider Enumeration Date:
08/23/2005

Additional Information

Authorized Official

Authorized Official Last Name:
BLACKARD
Authorized Official First Name:
DOUGLAS
Authorized Official Middle Name:
O.
Authorized Official Title or Position:
ADMINISTRATOR
Authorized Official Telephone Number:
713-795-0111

Provider Taxonomy Codes

  • Taxonomy code: 207Y00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 0844375-01 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".




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