Basic Information
Provider Information | |||||||||
NPI: | 1255385431 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | SOUTH GESSNER DIALYSIS FACILITY | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | BISSONNET DIALYSIS CENTER | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 8800 BISSONNET | ||||||||
Address2: | SUITE A | ||||||||
City: | HOUSTON | ||||||||
State: | TX | ||||||||
PostalCode: | 770742435 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7137731717 | ||||||||
FaxNumber: | 7137731716 | ||||||||
Practice Location | |||||||||
Address1: | 8800 BISSONNET | ||||||||
Address2: | SUITE A | ||||||||
City: | HOUSTON | ||||||||
State: | TX | ||||||||
PostalCode: | 770742435 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7137731717 | ||||||||
FaxNumber: | 7137731716 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/20/2006 | ||||||||
LastUpdateDate: | 04/01/2008 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | ELHAJ | ||||||||
AuthorizedOfficialFirstName: | WISAM | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
AuthorizedOfficialTelephone: | 7137731717 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QE0700X | 008322 | TX | Y |   | Ambulatory Health Care Facilities | Clinic/Center | End-Stage Renal Disease (ESRD) Treatment |
No ID Information.