1245811074 NPI number — DR. MICHAEL CHENGCHUN LI MD

Table of content: DR. MICHAEL CHENGCHUN LI MD (NPI 1245811074)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1245811074 NPI number — DR. MICHAEL CHENGCHUN LI MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
LI
Provider First Name:
MICHAEL
Provider Middle Name:
CHENGCHUN
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
M

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:
1245811074
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/16/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
8441 RIVERSIDE PKWY
Provider Second Line Business Mailing Address:
CLINICAL BUILDING 1, SUITE 1400
Provider Business Mailing Address City Name:
BRYAN
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
77807
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
979-436-9150
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
7877 WILLOW CHASE BLVD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
HOUSTON
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
77070-5934
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
832-869-4818
Provider Business Practice Location Address Fax Number:
832-241-2902
Provider Enumeration Date:
04/14/2021

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 390200000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2084P0800X , with the licence number: T9437 , 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)





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