Basic Information
| Provider Information | |||||||||
| NPI: | 1528142296 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | NORTHEAST PEDIATRICS ASSOCIATES OF HUMBLE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 104 MAIN ST | ||||||||
| Address2: | |||||||||
| City: | HUMBLE | ||||||||
| State: | TX | ||||||||
| PostalCode: | 77338 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2815487334 | ||||||||
| FaxNumber: | 2815487363 | ||||||||
| Practice Location | |||||||||
| Address1: | 104 E MAIN ST | ||||||||
| Address2: | |||||||||
| City: | HUMBLE | ||||||||
| State: | TX | ||||||||
| PostalCode: | 773384513 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2815487334 | ||||||||
| FaxNumber: | 2815487363 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/25/2006 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | SOLIS | ||||||||
| AuthorizedOfficialFirstName: | SANDRA | ||||||||
| AuthorizedOfficialMiddleName: | L | ||||||||
| AuthorizedOfficialTitleorPosition: | FINANCIAL MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 2815487334 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 0002DM | 01 | TX | BLUE CROSS BLUE SHIELD | OTHER |