1376629964 NPI number — DIGESTIVE DISEASE CONSULTANTS PA

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1376629964 NPI number — DIGESTIVE DISEASE CONSULTANTS PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
DIGESTIVE DISEASE CONSULTANTS 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:
1376629964
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/09/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
9816 MEMORIAL BLVD
Provider Second Line Business Mailing Address:
#206
Provider Business Mailing Address City Name:
HUMBLE
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
77338
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
281-446-8114
Provider Business Mailing Address Fax Number:
281-446-1158

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
9816 MEMORIAL BLVD
Provider Second Line Business Practice Location Address:
#206
Provider Business Practice Location Address City Name:
HUMBLE
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
77338
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
281-446-8114
Provider Business Practice Location Address Fax Number:
281-446-1158
Provider Enumeration Date:
10/27/2006

Additional Information

Authorized Official

Authorized Official Last Name:
WALLACE
Authorized Official First Name:
STARR
Authorized Official Middle Name:
LEE
Authorized Official Title or Position:
LVN OFFICE MANAGER
Authorized Official Telephone Number:
281-446-8114

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)

  • Identifier: 081671201 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".




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