1174762579 NPI number — CY-FAIR BONE AND JOINT

Table of content: (NPI 1174762579)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1174762579 NPI number — CY-FAIR BONE AND JOINT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CY-FAIR BONE AND JOINT
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:
1174762579
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/23/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
11800 FM 1960 RD W
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:
77065-3840
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
281-955-7577
Provider Business Mailing Address Fax Number:
281-955-5875

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
455 SCHOOL ST
Provider Second Line Business Practice Location Address:
SUITE 24
Provider Business Practice Location Address City Name:
TOMBALL
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
77375-4595
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
281-955-7577
Provider Business Practice Location Address Fax Number:
281-955-5875
Provider Enumeration Date:
02/10/2009

Additional Information

Authorized Official

Authorized Official Last Name:
MACK
Authorized Official First Name:
DAVID
Authorized Official Middle Name:
ROSS
Authorized Official Title or Position:
MANAGING PARTNER
Authorized Official Telephone Number:
281-955-7577

Provider Taxonomy Codes

  • Taxonomy code: 207X00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 00897R . This is a "MEDICARE PTAN" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".




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