Basic Information
| Provider Information | |||||||||
| NPI: | 1487972964 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GRAMZE | ||||||||
| FirstName: | NICKALAUS | ||||||||
| MiddleName: | LANE | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 6565 FANNIN ST | ||||||||
| Address2: | SUITE 1003 | ||||||||
| City: | HOUSTON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 770302703 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7134411100 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 755 E MCDOWELL RD FL 4 | ||||||||
| Address2: | |||||||||
| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 850062506 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6025213144 | ||||||||
| FaxNumber: | 6025213661 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/10/2010 | ||||||||
| LastUpdateDate: | 03/22/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 03/22/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | N4437 | TX | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207RC0000X | N4437 | TX | N | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease | 208000000X | N4437 | TX | N | Allopathic & Osteopathic Physicians | Pediatrics | 208M00000X | N4437 | TX | N | Allopathic & Osteopathic Physicians | Hospitalist | 207RC0000X | N4437 | AZ | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease |
ID Information
| ID | Type | State | Issuer | Description | 358659602 | 05 | TX | MEDICAID | 8FW349 | 01 | TX | BLUE CROSS BLUE SHIELD | OTHER | 358659601 | 05 | TX | MEDICAID | 8FW348 | 01 | TX | BCBS | OTHER |