Provider Demographics
NPI:1083880298
Name:RENAISSANCE NORTHEAST SURGERY CENTER
Entity Type:Organization
Organization Name:RENAISSANCE NORTHEAST SURGERY CENTER
Other - Org Name:RENAISSANCE SURGICAL CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:OMAR
Authorized Official - Middle Name:
Authorized Official - Last Name:KIGGUNDU
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:713-532-7311
Mailing Address - Street 1:PO BOX 669
Mailing Address - Street 2:
Mailing Address - City:HUMBLE
Mailing Address - State:TX
Mailing Address - Zip Code:77347-0669
Mailing Address - Country:US
Mailing Address - Phone:713-532-7311
Mailing Address - Fax:713-554-6658
Practice Address - Street 1:18929 HIGHWAY 59 N
Practice Address - Street 2:
Practice Address - City:HUMBLE
Practice Address - State:TX
Practice Address - Zip Code:77338-4270
Practice Address - Country:US
Practice Address - Phone:713-532-7311
Practice Address - Fax:281-446-6372
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-07
Last Update Date:2008-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX158696801Medicaid
TXASC163Medicare PIN