Basic Information
| Provider Information | |||||||||
| NPI: | 1669402335 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MEMORIAL HERMANN HEALTH SYSTEM | ||||||||
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| OtherOrganizationName: | MHHS PEARLAND OUTPATIENT IMAGING CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 301208 | ||||||||
| Address2: | |||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 753031208 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7133384127 | ||||||||
| FaxNumber: | 7133384158 | ||||||||
| Practice Location | |||||||||
| Address1: | 10905 MEMORIAL HERMANN DR | ||||||||
| Address2: | STE 104 | ||||||||
| City: | PEARLAND | ||||||||
| State: | TX | ||||||||
| PostalCode: | 775843490 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7139975236 | ||||||||
| FaxNumber: | 7133384158 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/05/2006 | ||||||||
| LastUpdateDate: | 06/26/2014 | ||||||||
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| AuthorizedOfficialLastName: | LARAWAY | ||||||||
| AuthorizedOfficialFirstName: | DENNIS | ||||||||
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| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 7132422707 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QR0200X | Y | Ambulatory Health Care Facilities | Clinic/Center | Radiology |
ID Information
| ID | Type | State | Issuer | Description | 146509804 | 05 | TX | MEDICAID |