1346360963 NPI number — OCCUPATIONAL MEDICINE OF LA PORTE P.A.

Table of content: (NPI 1346360963)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1346360963 NPI number — OCCUPATIONAL MEDICINE OF LA PORTE P.A.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
OCCUPATIONAL MEDICINE OF LA PORTE P.A.
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:
1346360963
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/18/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 1518
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LA PORTE
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
77572-1518
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
281-842-1200
Provider Business Mailing Address Fax Number:
281-842-1203

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
410 E FAIRMONT PKWY
Provider Second Line Business Practice Location Address:
SUITE A
Provider Business Practice Location Address City Name:
LA PORTE
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
77571-6498
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
281-842-1200
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
03/29/2007

Additional Information

Authorized Official

Authorized Official Last Name:
ASHBY
Authorized Official First Name:
GEORGE
Authorized Official Middle Name:
P.
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
281-842-1200

Provider Taxonomy Codes

  • Taxonomy code: 207QA0505X , with the licence number:  H 4864 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2083X0100X , with the licence number: H4864 , 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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