Basic Information
Provider Information | |||||||||
NPI: | 1275540700 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | SEABOLT | ||||||||
FirstName: | PHILIP | ||||||||
MiddleName: | BRIAN | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | PAC | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 5010 CRENSHAW RD | ||||||||
Address2: | STE 130 | ||||||||
City: | PASADENA | ||||||||
State: | TX | ||||||||
PostalCode: | 775054615 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2819912200 | ||||||||
FaxNumber: | 2819917700 | ||||||||
Practice Location | |||||||||
Address1: | 6807 EMMETT F LOWRY EXPRESSWAY | ||||||||
Address2: | SUITE 108 | ||||||||
City: | TEXAS CITY | ||||||||
State: | TX | ||||||||
PostalCode: | 77591 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4099455444 | ||||||||
FaxNumber: | 4099454133 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 08/01/2006 | ||||||||
LastUpdateDate: | 07/12/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 07/12/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | PA03217 | TX | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |   |
No ID Information.