1730155995 NPI number — SOUTHEAST TEXAS INTERNAL MEDICINE, PA

Table of content: (NPI 1730155995)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1730155995 NPI number — SOUTHEAST TEXAS INTERNAL MEDICINE, PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SOUTHEAST TEXAS INTERNAL MEDICINE, PA
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:
1730155995
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/23/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 20477
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BEAUMONT
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
77720-0477
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
409-729-7030
Provider Business Mailing Address Fax Number:
409-729-7015

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
7980 ANCHOR DR
Provider Second Line Business Practice Location Address:
BLDG. 400
Provider Business Practice Location Address City Name:
PORT ARTHUR
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
77642-8266
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
409-729-7030
Provider Business Practice Location Address Fax Number:
409-729-7015
Provider Enumeration Date:
02/27/2006

Additional Information

Authorized Official

Authorized Official Last Name:
GAMBRAH
Authorized Official First Name:
ANTHONY
Authorized Official Middle Name:
O.
Authorized Official Title or Position:
ATTENDING PHYSICIAN
Authorized Official Telephone Number:
409-729-7030

Provider Taxonomy Codes

  • Taxonomy code: 207R00000X , with the licence number:  J9675 , 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: 143474801 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".




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