1417981416 NPI number — EAST BELT FAMILY MEDICINE PA

Table of content: (NPI 1417981416)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1417981416 NPI number — EAST BELT FAMILY MEDICINE PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
EAST BELT FAMILY MEDICINE 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:
1417981416
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/07/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5402 E SAM HOUSTON PKWY N
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:
77015-3267
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
281-457-6535
Provider Business Mailing Address Fax Number:
281-457-6409

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5402 E SAM HOUSTON PKWY N
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
HOUSTON
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
77015-3267
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
281-457-6535
Provider Business Practice Location Address Fax Number:
281-457-6409
Provider Enumeration Date:
07/10/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
GARCIA
Authorized Official First Name:
DANIEL
Authorized Official Middle Name:
Authorized Official Title or Position:
PARTNER
Authorized Official Telephone Number:
281-458-8101

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , with the licence number:  K7739 , 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: 0061NJ . This is a "BCBS" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: DF1557 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".