1902267693 NPI number — TOMMY GLAZE

Table of content: TOMMY GLAZE (NPI 1902267693)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1902267693 NPI number — TOMMY GLAZE

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GLAZE
Provider First Name:
TOMMY
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:
M

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:
1902267693
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/09/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
9519 EAGLEWOOD GLEN TRL
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:
77083-6596
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
832-245-4571
Provider Business Mailing Address Fax Number:
832-664-9083

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
9519 EAGLEWOOD GLEN TRL
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:
77083-6596
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
832-245-4571
Provider Business Practice Location Address Fax Number:
832-664-9083
Provider Enumeration Date:
03/09/2016

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 311Z00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 004010X096A1 . This is a "COMMUNITY HEALTH SERVICES" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".




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