Basic Information
| Provider Information | |||||||||
| NPI: | 1518219104 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | EAST HOUSTON PHYSICIANS GROUP, PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 96706 | ||||||||
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| City: | HOUSTON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 772136706 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7133300766 | ||||||||
| FaxNumber: | 7133300794 | ||||||||
| Practice Location | |||||||||
| Address1: | 11821 EAST FWY STE 175 | ||||||||
| Address2: | |||||||||
| City: | HOUSTON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 770291960 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7133300766 | ||||||||
| FaxNumber: | 8778628370 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/08/2012 | ||||||||
| LastUpdateDate: | 04/02/2019 | ||||||||
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| AuthorizedOfficialLastName: | KILLAM | ||||||||
| AuthorizedOfficialFirstName: | RONALD | ||||||||
| AuthorizedOfficialMiddleName: | WAYNE | ||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 7133300766 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |
No ID Information.