Basic Information
| Provider Information | |||||||||
| NPI: | 1295816312 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | GROVES ER PHYSICIANS GROUP P A | ||||||||
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| Mailing Information | |||||||||
| Address1: | 14440 JOHN F KENNEDY BLVD | ||||||||
| Address2: | |||||||||
| City: | HOUSTON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 770325300 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8328861900 | ||||||||
| FaxNumber: | 2812271139 | ||||||||
| Practice Location | |||||||||
| Address1: | 5500 39TH STREET | ||||||||
| Address2: | |||||||||
| City: | GROVES | ||||||||
| State: | TX | ||||||||
| PostalCode: | 776192905 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4099625733 | ||||||||
| FaxNumber: | 4099635388 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/17/2006 | ||||||||
| LastUpdateDate: | 10/17/2008 | ||||||||
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| AuthorizedOfficialLastName: | KOENIG | ||||||||
| AuthorizedOfficialFirstName: | SCOTT | ||||||||
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| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 8328661900 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | 8328661900 | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 166546502 | 05 | TX | MEDICAID | 166546501 | 05 | TX | MEDICAID | 166546503 | 05 | TX | MEDICAID |