1083686091 NPI number — EAST HOUSTON MEDICINE & PEDIATRICS CLINIC PA

Table of content: (NPI 1083686091)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1083686091 NPI number — EAST HOUSTON MEDICINE & PEDIATRICS CLINIC PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
EAST HOUSTON MEDICINE & PEDIATRICS 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:
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:
1083686091
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/20/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 24308
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
HOUSTON
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
77229-4308
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
713-450-4455
Provider Business Mailing Address Fax Number:
713-450-4737

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
902 NORMANDY ST
Provider Second Line Business Practice Location Address:
STE 100
Provider Business Practice Location Address City Name:
HOUSTON
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
77015-4952
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
713-450-4455
Provider Business Practice Location Address Fax Number:
713-450-4737
Provider Enumeration Date:
02/03/2006

Additional Information

Authorized Official

Authorized Official Last Name:
WILSON
Authorized Official First Name:
CORNELIUS
Authorized Official Middle Name:
ANTOINNE
Authorized Official Title or Position:
OWNER PRESIDENT
Authorized Official Telephone Number:
713-450-4455

Provider Taxonomy Codes

  • Taxonomy code: 207R00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207RA0000X , with the licence number: J2845 , 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: 0081QD . This is a "BLUE CROSS" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 00L66J . This is a "BCBS" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 184593501 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 45D1000292 . This is a "CLIA" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 184593502 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".




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