Basic Information
| Provider Information | |||||||||
| NPI: | 1417401258 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | UT PHYSICIANS | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | UT PHYSICIANS COMMUNITY HEALTH & WELLNESS CENTER -SOUTHWEST | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 10623 BELLAIRE BLVD | ||||||||
| Address2: | SUITE C280 | ||||||||
| City: | HOUSTON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 770725242 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7134865900 | ||||||||
| FaxNumber: | 7134865901 | ||||||||
| Practice Location | |||||||||
| Address1: | 10623 BELLAIRE BLVD | ||||||||
| Address2: | SUITE C280 | ||||||||
| City: | HOUSTON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 770725242 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7134865900 | ||||||||
| FaxNumber: | 7134865901 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/10/2016 | ||||||||
| LastUpdateDate: | 08/10/2016 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | KAMAL | ||||||||
| AuthorizedOfficialFirstName: | FAHAD | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | PRACTICE ADMINISTRATOR | ||||||||
| AuthorizedOfficialTelephone: | 7134865915 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | MBA,MS, CLSSGB | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261Q00000X | Y | Ambulatory Health Care Facilities | Clinic/Center |
ID Information
| ID | Type | State | Issuer | Description | 1073811832 | 05 | TX | MEDICAID | 1457775058 | 05 | TX | MEDICAID | 1194919027 | 05 | TX | MEDICAID | 1225299753 | 05 | TX | MEDICAID | 1407248149 | 05 | TX | MEDICAID |