Basic Information
| Provider Information | |||||||||
| NPI: | 1154574093 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | C H WILKINSON PHYSICIAN NETWORK | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | CHRISTUS MEDICAL GROUP | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1700 WEST LOOP SOUTH | ||||||||
| Address2: | SUITE 400B | ||||||||
| City: | HOUSTON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 770273005 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7132772222 | ||||||||
| FaxNumber: | 7136130934 | ||||||||
| Practice Location | |||||||||
| Address1: | 1710 BROADWAY STREET | ||||||||
| Address2: | |||||||||
| City: | PEARLAND | ||||||||
| State: | TX | ||||||||
| PostalCode: | 775815604 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7132772222 | ||||||||
| FaxNumber: | 7136130934 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/23/2008 | ||||||||
| LastUpdateDate: | 10/30/2008 | ||||||||
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| AuthorizedOfficialLastName: | MIKULECKY | ||||||||
| AuthorizedOfficialFirstName: | DONNA | ||||||||
| AuthorizedOfficialMiddleName: | J | ||||||||
| AuthorizedOfficialTitleorPosition: | CEO PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 7132772208 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
No ID Information.