1154945111 NPI number — GASTROENTEROLOGY OF TEXAS, PLLC

Table of content: (NPI 1154945111)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1154945111 NPI number — GASTROENTEROLOGY OF TEXAS, PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
GASTROENTEROLOGY OF TEXAS, 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:
1154945111
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/02/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
6606 FM 1488 RD STE 148-368
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MAGNOLIA
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
77354-2544
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2510 S LOOP 336 W
Provider Second Line Business Practice Location Address:
STE 336
Provider Business Practice Location Address City Name:
CONROE
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
77304
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
713-955-2889
Provider Business Practice Location Address Fax Number:
254-780-0332
Provider Enumeration Date:
06/04/2020

Additional Information

Authorized Official

Authorized Official Last Name:
CLARK
Authorized Official First Name:
MATTHEW
Authorized Official Middle Name:
TIMOTHY
Authorized Official Title or Position:
PHYSICIAN OWNER
Authorized Official Telephone Number:
832-510-5711

Provider Taxonomy Codes

  • Taxonomy code: 207RG0100X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





Copyright © 2007-2024 www.npivalidator.com