1316252927 NPI number — NORTHSIDE PATHOLOGY GROUP PLLC

Table of content: (NPI 1316252927)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1316252927 NPI number — NORTHSIDE PATHOLOGY GROUP PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
NORTHSIDE PATHOLOGY GROUP PLLC
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:
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:
1316252927
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/18/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
510 W TIDWELL RD
Provider Second Line Business Mailing Address:
PATHOLOGY / LABORATORY
Provider Business Mailing Address City Name:
HOUSTON
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
77091-4339
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
832-443-9071
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
510 W TIDWELL RD
Provider Second Line Business Practice Location Address:
PATHOLOGY / LABORATORY
Provider Business Practice Location Address City Name:
HOUSTON
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
77091-4339
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
832-443-9071
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
08/09/2010

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
CERVANTES-VAZQUEZ
Authorized Official First Name:
MARIO
Authorized Official Middle Name:
Authorized Official Title or Position:
PRESIDENT, MANAGER
Authorized Official Telephone Number:
281-618-8515

Provider Taxonomy Codes

  • Taxonomy code: 207ZP0102X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: H7953 . This is a "MEDICAL LICENSE" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".