Basic Information
Provider Information | |||||||||
NPI: | 1386827558 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | MEMORIAL HERMANN HOSPITAL SYSTEM | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | MEMORIAL HERMANN MEMORIAL CITY RADIATION THERAPY RR | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 201367 | ||||||||
Address2: |   | ||||||||
City: | HOUSTON | ||||||||
State: | TX | ||||||||
PostalCode: | 772161367 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7133384127 | ||||||||
FaxNumber: | 7133384158 | ||||||||
Practice Location | |||||||||
Address1: | 902 FROSTWOOD DR | ||||||||
Address2: |   | ||||||||
City: | HOUSTON | ||||||||
State: | TX | ||||||||
PostalCode: | 770242420 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7132423700 | ||||||||
FaxNumber: | 7133384158 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 12/11/2007 | ||||||||
LastUpdateDate: | 10/14/2011 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | BROWNAWELL | ||||||||
AuthorizedOfficialFirstName: | H. | ||||||||
AuthorizedOfficialMiddleName: | JEFFREY | ||||||||
AuthorizedOfficialTitleorPosition: | CHIEF REVENUE OFFICER | ||||||||
AuthorizedOfficialTelephone: | 7132422785 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | MR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QR0200X |   |   | Y |   | Ambulatory Health Care Facilities | Clinic/Center | Radiology |
No ID Information.