1194859629 NPI number — ENTRAMED, INC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1194859629 NPI number — ENTRAMED, INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ENTRAMED, INC
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:
1194859629
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/25/2025
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
27905 COMMERCIAL PARK RD STE 240
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
TOMBALL
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
77375-6580
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
713-955-2123
Provider Business Mailing Address Fax Number:
281-742-2589

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
27905 COMMERCIAL PARK RD STE 240
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
TOMBALL
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
77375-6580
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
713-955-2123
Provider Business Practice Location Address Fax Number:
281-742-2589
Provider Enumeration Date:
03/15/2007

Additional Information

Authorized Official

Authorized Official Last Name:
CRABB
Authorized Official First Name:
JEREMY
Authorized Official Middle Name:
W
Authorized Official Title or Position:
CO-CEO
Authorized Official Telephone Number:
817-600-6233

Provider Taxonomy Codes

  • Taxonomy code: 133V00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 174N00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 332B00000X , with the licence number: 0051466 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 332BP3500X , with the licence number: 0051466 , 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: 1194859629 , issued by the state of ( MT ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1194859629 , issued by the state of ( CO ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1653815 , issued by the state of ( AK ) . This identifiers is of the category "MEDICAID".
  • Identifier: 10026750400 , issued by the state of ( NE ) . This identifiers is of the category "MEDICAID".
  • Identifier: 28430310 , issued by the state of ( NM ) . This identifiers is of the category "MEDICAID".
  • Identifier: 145697201 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 145698001 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 2106483 , issued by the state of ( WA ) . This identifiers is of the category "MEDICAID".




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