1629404637 NPI number — BEAUMONT ER PHYSICIANS 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 1629404637 NPI number — BEAUMONT ER PHYSICIANS PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BEAUMONT ER PHYSICIANS 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:
BEAUMONT ER PHYSICIANS
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:
1629404637
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/17/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
12743 CAPRICORN ST STE 400
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
STAFFORD
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
77477-3996
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
713-343-9651
Provider Business Mailing Address Fax Number:
409-515-1121

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4004 COLLEGE ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BEAUMONT
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
77707-4004
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
713-343-9651
Provider Business Practice Location Address Fax Number:
409-515-1121
Provider Enumeration Date:
09/23/2013

Additional Information

Authorized Official

Authorized Official Last Name:
ORSAK
Authorized Official First Name:
SHANNON
Authorized Official Middle Name:
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
281-343-9975

Provider Taxonomy Codes

  • Taxonomy code: 207P00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 261QE0002X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 00567J . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".




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