1629524376 NPI number — NUPHYSICIA HEALTH OF TEXAS

Table of content: (NPI 1629524376)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1629524376 NPI number — NUPHYSICIA HEALTH OF TEXAS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
NUPHYSICIA HEALTH OF TEXAS
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:
1629524376
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/31/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4625 SOUTHWEST FREEWAY
Provider Second Line Business Mailing Address:
SUITE 142
Provider Business Mailing Address City Name:
HOUSTON
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
77027
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
713-358-9271
Provider Business Mailing Address Fax Number:
713-358-9269

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4625 SOUTHWEST FWY
Provider Second Line Business Practice Location Address:
SUITE 142
Provider Business Practice Location Address City Name:
HOUSTON
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
77027-7100
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
713-358-9271
Provider Business Practice Location Address Fax Number:
713-358-9269
Provider Enumeration Date:
08/31/2016

Additional Information

Authorized Official

Authorized Official Last Name:
BOULTINGHOUSE
Authorized Official First Name:
OSCAR
Authorized Official Middle Name:
WILLIAM
Authorized Official Title or Position:
MEDICAL DIRECTOR
Authorized Official Telephone Number:
713-358-9271

Provider Taxonomy Codes

  • Taxonomy code: 172V00000X , with the licence number:  G2256 , 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: G2256 . This is a "MEDICAL LISCENSE" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".




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