Provider Demographics
NPI:1003127606
Name:MEMORIAL HERMANN ENDOSCOPY CENTER NORTH FREEWAY LLC
Entity Type:Organization
Organization Name:MEMORIAL HERMANN ENDOSCOPY CENTER NORTH FREEWAY LLC
Other - Org Name:MEMORIAL HERMANN ENDOSCOPY CENTER NORTH LOOP
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OFFICER/AUTHORIZED OFFICIAL
Authorized Official - Prefix:
Authorized Official - First Name:PETER
Authorized Official - Middle Name:
Authorized Official - Last Name:BLACH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:713-343-0832
Mailing Address - Street 1:14201 DALLAS PKWY
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75254-2916
Mailing Address - Country:US
Mailing Address - Phone:713-457-2750
Mailing Address - Fax:713-457-2751
Practice Address - Street 1:1900 NORTH LOOP W
Practice Address - Street 2:STE 550
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77018-8100
Practice Address - Country:US
Practice Address - Phone:713-457-2750
Practice Address - Fax:713-457-2751
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-06-29
Last Update Date:2021-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX130220261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX2205007Medicaid
TXASC419Medicare PIN
TX45C0001363Medicare Oscar/Certification