Basic Information
| Provider Information | |||||||||
| NPI: | 1154480689 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BAXTER | ||||||||
| FirstName: | THOMAS | ||||||||
| MiddleName: | LEROY | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | III | ||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6550 FANNIN ST | ||||||||
| Address2: | SUITE 1101 | ||||||||
| City: | HOUSTON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 770302717 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7134411006 | ||||||||
| FaxNumber: | 7137902727 | ||||||||
| Practice Location | |||||||||
| Address1: | 6550 FANNIN ST | ||||||||
| Address2: | SUITE 1101 | ||||||||
| City: | HOUSTON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 770302717 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7134411006 | ||||||||
| FaxNumber: | 7137902727 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/08/2006 | ||||||||
| LastUpdateDate: | 06/13/2012 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | F0869 | TX | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | P00757544 | 01 | TX | MEDICARE RAILROAD | OTHER | 033036703 | 05 | TX | MEDICAID | P01030939 | 01 | TX | RR MEDICARE | OTHER | 33036702 | 05 | TX | MEDICAID | 1154480689 | 01 | TX | BLUE CROSS BLUE SHIELD | OTHER |