Provider Demographics
NPI:1114227303
Name:SOUTH MAIN MEDICAL CLINIC
Entity Type:Organization
Organization Name:SOUTH MAIN MEDICAL CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:PETER
Authorized Official - Middle Name:
Authorized Official - Last Name:WANGURI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:713-668-1166
Mailing Address - Street 1:10021 S MAIN ST
Mailing Address - Street 2:SUITE B3
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77025-5224
Mailing Address - Country:US
Mailing Address - Phone:713-668-1166
Mailing Address - Fax:713-668-8159
Practice Address - Street 1:10021 S MAIN ST
Practice Address - Street 2:SUITE B3
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77025-5224
Practice Address - Country:US
Practice Address - Phone:713-668-1166
Practice Address - Fax:713-668-8159
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-10-22
Last Update Date:2010-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty