1528050150 NPI number — BEAR CREEK PEDIATRIC CLINIC PA

Table of content: (NPI 1528050150)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1528050150 NPI number — BEAR CREEK PEDIATRIC CLINIC PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BEAR CREEK PEDIATRIC CLINIC 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:
SHOBHANA KAMDAR, MD
Provider Other Organization Name Type Code:
5
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:
1528050150
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4654 HWY 6 N
Provider Second Line Business Mailing Address:
STE 307
Provider Business Mailing Address City Name:
HOUSTON
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
77084-2879
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
281-463-9339
Provider Business Mailing Address Fax Number:
281-463-2921

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4654 HWY 6 N
Provider Second Line Business Practice Location Address:
STE 307
Provider Business Practice Location Address City Name:
HOUSTON
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
77084-2879
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
281-463-9339
Provider Business Practice Location Address Fax Number:
281-463-2921
Provider Enumeration Date:
08/19/2005

Additional Information

Authorized Official

Authorized Official Last Name:
KAMDAR
Authorized Official First Name:
SHOBHANA
Authorized Official Middle Name:
JAGAT
Authorized Official Title or Position:
PRESIDENT DIRECTOR PEDIATRICIAN
Authorized Official Telephone Number:
281-463-9339

Provider Taxonomy Codes

  • Taxonomy code: 208000000X , with the licence number:  E 7433 , 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: TP9120491901 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".




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