1457502304 NPI number — PEDIATRIC HOSPITALIST OF CONROE PLLC

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 1457502304 NPI number — PEDIATRIC HOSPITALIST OF CONROE PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PEDIATRIC HOSPITALIST OF CONROE PLLC
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:
1457502304
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/20/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
500 MEDICAL CENTER BLVD
Provider Second Line Business Mailing Address:
STE.# 300
Provider Business Mailing Address City Name:
CONROE
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
77304-2889
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
936-539-5000
Provider Business Mailing Address Fax Number:
936-539-5027

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
500 MEDICAL CENTER BLVD
Provider Second Line Business Practice Location Address:
STE.# 300
Provider Business Practice Location Address City Name:
CONROE
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
77304-2889
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
936-539-5000
Provider Business Practice Location Address Fax Number:
936-539-5027
Provider Enumeration Date:
10/08/2008

Additional Information

Authorized Official

Authorized Official Last Name:
EVANS
Authorized Official First Name:
TODD
Authorized Official Middle Name:
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
713-852-1500

Provider Taxonomy Codes

  • Taxonomy code: 208000000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 198415501 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".




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