1871666271 NPI number — CENTRAL TEXAS HEART CENTER

Table of content: (NPI 1871666271)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1871666271 NPI number — CENTRAL TEXAS HEART CENTER

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CENTRAL TEXAS HEART CENTER
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:
PROF ASSOCIATION
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:
1871666271
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/25/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2700 E 29TH ST
Provider Second Line Business Mailing Address:
SUITE 220
Provider Business Mailing Address City Name:
BRYAN
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
77802-2531
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
979-774-4008
Provider Business Mailing Address Fax Number:
979-774-7893

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2700 E 29TH STREET
Provider Second Line Business Practice Location Address:
SUITE 220
Provider Business Practice Location Address City Name:
BRYAN
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
77802-2586
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
979-774-4008
Provider Business Practice Location Address Fax Number:
979-774-7893
Provider Enumeration Date:
11/16/2006

Additional Information

Authorized Official

Authorized Official Last Name:
WIGLEY
Authorized Official First Name:
KENNON
Authorized Official Middle Name:
D
Authorized Official Title or Position:
PHYSICIAN
Authorized Official Telephone Number:
979-774-4008

Provider Taxonomy Codes

  • Taxonomy code: 207RC0000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 082010201 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: CD6802 . This is a "RAILROAD MEDICARE" identifier . This identifiers is of the category "OTHER".




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