1194970756 NPI number — PEARLAND DIAGNOSTIC CLINIC, PA

Table of content: DR. MARK E THOMPSON MD (NPI 1902876733)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1194970756 NPI number — PEARLAND DIAGNOSTIC CLINIC, PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PEARLAND DIAGNOSTIC CLINIC, PA
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:
1194970756
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/19/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1834 BROADWAY ST
Provider Second Line Business Mailing Address:
SUITE 102
Provider Business Mailing Address City Name:
PEARLAND
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
77581-5668
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
281-997-8181
Provider Business Mailing Address Fax Number:
281-997-8184

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1834 BROADWAY ST
Provider Second Line Business Practice Location Address:
SUITE 102
Provider Business Practice Location Address City Name:
PEARLAND
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
77581-5668
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
281-997-8181
Provider Business Practice Location Address Fax Number:
281-997-8184
Provider Enumeration Date:
11/24/2008

Additional Information

Authorized Official

Authorized Official Last Name:
ROOSTH
Authorized Official First Name:
JOSEPH
Authorized Official Middle Name:
H
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
281-997-8181

Provider Taxonomy Codes

  • Taxonomy code: 261QP2300X , with the licence number:  MDH7345 , 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: 128481204 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".




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