1679903967 NPI number — EBD BEMC BURLESON, LLC

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 1679903967 NPI number — EBD BEMC BURLESON, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
EBD BEMC BURLESON, LLC
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:
6
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:
1679903967
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/10/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
8686 NEW TRAILS DR
Provider Second Line Business Mailing Address:
SUITE 100
Provider Business Mailing Address City Name:
THE WOODLANDS
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
77381-1176
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
716-637-1144
Provider Business Mailing Address Fax Number:
281-292-3585

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
12500 SOUTH FWY
Provider Second Line Business Practice Location Address:
SUITE 100
Provider Business Practice Location Address City Name:
BURLESON
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
76028-7004
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
214-294-6250
Provider Business Practice Location Address Fax Number:
713-637-1305
Provider Enumeration Date:
11/22/2013

Additional Information

Authorized Official

Authorized Official Last Name:
JOHNSON
Authorized Official First Name:
TINA
Authorized Official Middle Name:
Authorized Official Title or Position:
SR MED STAFF & PROVIDER ENROLLMENT
Authorized Official Telephone Number:
713-637-1146

Provider Taxonomy Codes

  • Taxonomy code: 261QA1903X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 282N00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 348928802 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 348928801 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".




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