1871666271 NPI number — CENTRAL TEXAS HEART CENTER

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1871666271 NPI number — CENTRAL TEXAS HEART CENTER

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CENTRAL TEXAS HEART CENTER
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:
PROF ASSOCIATION
Provider Other Organization Name Type Code:
5
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:
1871666271
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/25/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2700 E 29TH ST
Provider Second Line Business Mailing Address:
SUITE 220
Provider Business Mailing Address City Name:
BRYAN
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
77802-2531
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
979-774-4008
Provider Business Mailing Address Fax Number:
979-774-7893

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2700 E 29TH STREET
Provider Second Line Business Practice Location Address:
SUITE 220
Provider Business Practice Location Address City Name:
BRYAN
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
77802-2586
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
979-774-4008
Provider Business Practice Location Address Fax Number:
979-774-7893
Provider Enumeration Date:
11/16/2006

Additional Information

Authorized Official

Authorized Official Last Name:
WIGLEY
Authorized Official First Name:
KENNON
Authorized Official Middle Name:
D
Authorized Official Title or Position:
PHYSICIAN
Authorized Official Telephone Number:
979-774-4008

Provider Taxonomy Codes

  • Taxonomy code: 207RC0000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 082010201 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: CD6802 . This is a "RAILROAD MEDICARE" identifier . This identifiers is of the category "OTHER".




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