1770688483 NPI number — ST. JOSEPH DERMATOPATHOLOGY, P.A.

Table of content: (NPI 1770688483)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1770688483 NPI number — ST. JOSEPH DERMATOPATHOLOGY, P.A.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ST. JOSEPH DERMATOPATHOLOGY, P.A.
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:
1770688483
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/11/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
6909 GREENBRIAR ST
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:
77030-3205
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
713-660-9444
Provider Business Mailing Address Fax Number:
713-660-9466

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
6909 GREENBRIAR ST
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:
77030-3205
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
713-660-9444
Provider Business Practice Location Address Fax Number:
713-660-9466
Provider Enumeration Date:
09/14/2006

Additional Information

Authorized Official

Authorized Official Last Name:
TSCHEN
Authorized Official First Name:
JAIME
Authorized Official Middle Name:
ANTONIO
Authorized Official Title or Position:
DIRECTOR
Authorized Official Telephone Number:
713-660-9444

Provider Taxonomy Codes

  • Taxonomy code: 291U00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 00000055LC . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 0000CL8261 . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: P00061050 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 16470502 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 45D0858722 . This is a "CLIA" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".




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