1457385551 NPI number — EAST TEXAS EYE CENTER 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 1457385551 NPI number — EAST TEXAS EYE CENTER PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
EAST TEXAS EYE CENTER 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:
1457385551
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/05/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
18700 W LAKE HOUSTON PKWY
Provider Second Line Business Mailing Address:
STE B101
Provider Business Mailing Address City Name:
HUMBLE
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
77346-3349
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
281-812-4000
Provider Business Mailing Address Fax Number:
281-812-3331

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
901 E HOUSTON ST
Provider Second Line Business Practice Location Address:
STE B
Provider Business Practice Location Address City Name:
CLEVELAND
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
77327-4602
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
281-659-2020
Provider Business Practice Location Address Fax Number:
281-659-2030
Provider Enumeration Date:
07/11/2006

Additional Information

Authorized Official

Authorized Official Last Name:
SHRUM
Authorized Official First Name:
K
Authorized Official Middle Name:
RAY
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
281-659-2020

Provider Taxonomy Codes

  • Taxonomy code: 152W00000X , with the licence number:  02830TG , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207W00000X , with the licence number: L2649 , 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: 918304 . This is a "BLOCK VISION" identifier . This identifiers is of the category "OTHER".
  • Identifier: 21210202328 . This is a "BEECH STREET" identifier . This identifiers is of the category "OTHER".
  • Identifier: DE8958 . This is a "MEDICARE RAILROAD" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 0084GS . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 180044544 . This is a "MEDICARE RAILROAD" identifier . This identifiers is of the category "OTHER".
  • Identifier: 7114117 . This is a "AETNA" identifier . This identifiers is of the category "OTHER".
  • Identifier: 145198102 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 975250 . This is a "ONE HEALTH PLAN" identifier . This identifiers is of the category "OTHER".
  • Identifier: 4119904 . This is a "CIGNA" identifier . This identifiers is of the category "OTHER".
  • Identifier: 5248990 . This is a "FIRST HEALTH" identifier . This identifiers is of the category "OTHER".
  • Identifier: 145198103 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 21210202328 . This is a "BEECHSTREET" identifier . This identifiers is of the category "OTHER".
  • Identifier: 5248990 . This is a "CCN" identifier . This identifiers is of the category "OTHER".




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