1386689958 NPI number — MCGOWEN ST. CHILDREN'S CLINIC & PREVENTIVE MEDICINE INSTITUTE

Table of content: (NPI 1386689958)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1386689958 NPI number — MCGOWEN ST. CHILDREN'S CLINIC & PREVENTIVE MEDICINE INSTITUTE

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MCGOWEN ST. CHILDREN'S CLINIC & PREVENTIVE MEDICINE INSTITUTE
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:
1386689958
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/07/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 667638
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:
77266-7638
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
713-655-1006
Provider Business Mailing Address Fax Number:
713-571-9630

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2900 SMITH ST
Provider Second Line Business Practice Location Address:
STE 101
Provider Business Practice Location Address City Name:
HOUSTON
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
77006-3446
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
713-655-1006
Provider Business Practice Location Address Fax Number:
713-571-9630
Provider Enumeration Date:
06/18/2006

Additional Information

Authorized Official

Authorized Official Last Name:
BROBBEY
Authorized Official First Name:
GWENDOLYN
Authorized Official Middle Name:
ELIZABETH
Authorized Official Title or Position:
PHYSICIAN/OWNER/PRES.OF CORPORATION
Authorized Official Telephone Number:
713-655-1006

Provider Taxonomy Codes

  • Taxonomy code: 208000000X , with the licence number:  G0899 , 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: 31381 . This is a "AMERICAN BD OF PEDIATRICS" identifier . This identifiers is of the category "OTHER".
  • Identifier: 236-282-0 . This is a "ECFMG NUMBER" identifier . This identifiers is of the category "OTHER".
  • Identifier: 48268 . This is a "MASS BD OF REGISTRATION" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: G0899 . This is a "ST. BD OF MED EXAMINERS" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: S0045716 . This is a "STATE DPS NUMBER" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".




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