1114346723 NPI number — CARDIAC CATH LAB OF BRYAN COLLEGE STATION, LP

Table of content: (NPI 1114346723)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1114346723 NPI number — CARDIAC CATH LAB OF BRYAN COLLEGE STATION, LP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CARDIAC CATH LAB OF BRYAN COLLEGE STATION, LP
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:
1114346723
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/09/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
DEPT# 3020, PO BOX 4417
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:
77210-4417
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
610-644-8900
Provider Business Mailing Address Fax Number:
484-924-0053

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3201 UNIVERSITY DR E
Provider Second Line Business Practice Location Address:
SUITE 420
Provider Business Practice Location Address City Name:
BRYAN
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
77802-3475
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
979-485-9922
Provider Business Practice Location Address Fax Number:
979-485-9923
Provider Enumeration Date:
04/10/2014

Additional Information

Authorized Official

Authorized Official Last Name:
BEMIS
Authorized Official First Name:
KELLY
Authorized Official Middle Name:
Authorized Official Title or Position:
AUTHORIZED OFFICIAL
Authorized Official Telephone Number:
858-722-2358

Provider Taxonomy Codes

  • Taxonomy code: 261QM1300X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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