Basic Information
| Provider Information | |||||||||
| NPI: | 1114346723 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | CARDIAC CATH LAB OF BRYAN COLLEGE STATION, LP | ||||||||
| LastName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | THE HEART AND VASCULAR CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | DEPT# 3020, PO BOX 4417 | ||||||||
| Address2: | |||||||||
| City: | HOUSTON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 772104417 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6106448900 | ||||||||
| FaxNumber: | 4849240053 | ||||||||
| Practice Location | |||||||||
| Address1: | 3201 UNIVERSITY DR E | ||||||||
| Address2: | SUITE 420 | ||||||||
| City: | BRYAN | ||||||||
| State: | TX | ||||||||
| PostalCode: | 778023475 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7138127586 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/10/2014 | ||||||||
| LastUpdateDate: | 08/15/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | MILLER | ||||||||
| AuthorizedOfficialFirstName: | GREGG | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | SR. VICE PREIDENT | ||||||||
| AuthorizedOfficialTelephone: | 6106448900 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | 08/15/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM1300X | Y | Ambulatory Health Care Facilities | Clinic/Center | Multi-Specialty |
No ID Information.