Basic Information
Provider Information | |||||||||
NPI: | 1629577416 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | STEPHEN F AUSTIN COMMUNITY HEALTH CENTER, INC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | PEARLAND FAMILY HEALTH CENTER | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1111 W ADOUE ST | ||||||||
Address2: |   | ||||||||
City: | ALVIN | ||||||||
State: | TX | ||||||||
PostalCode: | 775112718 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2818241480 | ||||||||
FaxNumber: | 2812206407 | ||||||||
Practice Location | |||||||||
Address1: | 2552 BROADWAY ST STE 102 | ||||||||
Address2: |   | ||||||||
City: | PEARLAND | ||||||||
State: | TX | ||||||||
PostalCode: | 775814904 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2818241480 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 02/07/2018 | ||||||||
LastUpdateDate: | 01/22/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | SMITH | ||||||||
AuthorizedOfficialFirstName: | BRANDY | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | CREDENTIALING COORDINATOR | ||||||||
AuthorizedOfficialTelephone: | 2818241480 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 01/22/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QF0400X |   |   | N |   | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) | 207Q00000X |   |   | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |   |
No ID Information.