1124117411 NPI number — LIBERTY DIAGNOSTIC CLINIC

Table of content: (NPI 1124117411)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1124117411 NPI number — LIBERTY DIAGNOSTIC CLINIC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
LIBERTY DIAGNOSTIC CLINIC
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:
1124117411
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/16/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 1905
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BAYTOWN
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
77522-1905
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
281-427-2149
Provider Business Mailing Address Fax Number:
281-427-4390

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2802 GARTH RD STE 203
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BAYTOWN
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
77521-3924
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
281-427-2149
Provider Business Practice Location Address Fax Number:
281-427-4390
Provider Enumeration Date:
10/12/2006

Additional Information

Authorized Official

Authorized Official Last Name:
HAMID
Authorized Official First Name:
BASSAM
Authorized Official Middle Name:
A
Authorized Official Title or Position:
MD OWNER
Authorized Official Telephone Number:
281-427-2149

Provider Taxonomy Codes

  • Taxonomy code: 207R00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 085825001 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 136448107 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".




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