Basic Information
Provider Information | |||||||||
NPI: | 1912154600 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | C H WILKINSON PHYSICIAN NETWORK | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | CHRISTUS MEDICAL GROUP | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1700 WEST LOOP SOUTH | ||||||||
Address2: | SUITE 400B | ||||||||
City: | HOUSTON | ||||||||
State: | TX | ||||||||
PostalCode: | 770273005 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7132772222 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 155 LOUETTA CROSSING | ||||||||
Address2: |   | ||||||||
City: | SPRING | ||||||||
State: | TX | ||||||||
PostalCode: | 773733007 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2815280278 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 08/25/2008 | ||||||||
LastUpdateDate: | 08/25/2008 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | RETKOWSKI | ||||||||
AuthorizedOfficialFirstName: | RONALD | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | VP RETAIL OPERATIONS | ||||||||
AuthorizedOfficialTelephone: | 7133718545 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X |   |   | Y | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
No ID Information.