Basic Information
| Provider Information | |||||||||
| NPI: | 1023002524 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | RIVER OAKS SURGICAL CENTER, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4120 SOUTHWEST FWY | ||||||||
| Address2: | STE 100 | ||||||||
| City: | HOUSTON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 770277339 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7136268500 | ||||||||
| FaxNumber: | 7136268560 | ||||||||
| Practice Location | |||||||||
| Address1: | 4120 SOUTHWEST FWY | ||||||||
| Address2: | STE 100 | ||||||||
| City: | HOUSTON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 770277339 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7136268500 | ||||||||
| FaxNumber: | 7136268560 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/12/2005 | ||||||||
| LastUpdateDate: | 05/18/2012 | ||||||||
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| AuthorizedOfficialLastName: | DEESE | ||||||||
| AuthorizedOfficialFirstName: | JERRY | ||||||||
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| AuthorizedOfficialTitleorPosition: | MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 7136268500 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QA0005X | Y | Ambulatory Health Care Facilities | Clinic/Center | Ambulatory Family Planning Facility |
ID Information
| ID | Type | State | Issuer | Description | 087948801 | 05 | TX | MEDICAID |