Basic Information
| Provider Information | |||||||||
| NPI: | 1679717763 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | 2920 MEDICAL MANAGMENT GROUP, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6225 FM 2920 | ||||||||
| Address2: | STE 100 | ||||||||
| City: | SPRING | ||||||||
| State: | TX | ||||||||
| PostalCode: | 77379 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2812570404 | ||||||||
| FaxNumber: | 2816054563 | ||||||||
| Practice Location | |||||||||
| Address1: | 6225 FM 2920 | ||||||||
| Address2: | STE 150 | ||||||||
| City: | SPRING | ||||||||
| State: | TX | ||||||||
| PostalCode: | 77379 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2812570404 | ||||||||
| FaxNumber: | 2816054563 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/21/2009 | ||||||||
| LastUpdateDate: | 10/09/2014 | ||||||||
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| AuthorizedOfficialLastName: | GORRELA | ||||||||
| AuthorizedOfficialFirstName: | SUSHMA | ||||||||
| AuthorizedOfficialMiddleName: | VEERA | ||||||||
| AuthorizedOfficialTitleorPosition: | M.D. | ||||||||
| AuthorizedOfficialTelephone: | 2812570404 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Emergency Medicine | 207R00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | 207ZP0102X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pathology | Anatomic Pathology & Clinical Pathology | 207L00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Anesthesiology | 146N00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Emergency Medical Service Providers | Emergency Medical Technician, Basic |
No ID Information.