1225130578 NPI number — C H WILKINSON PHYSICIAN NETWORK

Table of content: (NPI 1225130578)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1225130578 NPI number — C H WILKINSON PHYSICIAN NETWORK

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
C H WILKINSON PHYSICIAN NETWORK
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:
CHRISTUS MEDICAL GROUP
Provider Other Organization Name Type Code:
5
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:
1225130578
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2600 NORTH LOOP W
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
HOUSTON
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
77092-8903
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
713-681-8877
Provider Business Mailing Address Fax Number:
713-812-2063

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
HIGHWAY 107 AND LA FERIA AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SANTA ROSA
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
78593
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
956-636-1805
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
09/05/2006

Additional Information

Authorized Official

Authorized Official Last Name:
MIKULECKY
Authorized Official First Name:
DONNA
Authorized Official Middle Name:
Authorized Official Title or Position:
CFO
Authorized Official Telephone Number:
713-681-8877

Provider Taxonomy Codes

  • Taxonomy code: 261QR1300X , with the licence number:  K7201 , 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)





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