Provider Demographics
NPI:1194838318
Name:SOUTHEAST TEXAS HYPERBARIC MEDICINE CENTER, P.A.
Entity Type:Organization
Organization Name:SOUTHEAST TEXAS HYPERBARIC MEDICINE CENTER, P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:BRADLEY
Authorized Official - Middle Name:A
Authorized Official - Last Name:PONTANI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:936-539-7071
Mailing Address - Street 1:500 MEDICAL CENTER BLVD
Mailing Address - Street 2:STE #110
Mailing Address - City:CONROE
Mailing Address - State:TX
Mailing Address - Zip Code:77304-2889
Mailing Address - Country:US
Mailing Address - Phone:936-539-7074
Mailing Address - Fax:936-539-9100
Practice Address - Street 1:500 MEDICAL CENTER BLVD
Practice Address - Street 2:STE #110
Practice Address - City:CONROE
Practice Address - State:TX
Practice Address - Zip Code:77304-2889
Practice Address - Country:US
Practice Address - Phone:936-539-7074
Practice Address - Fax:936-539-9100
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-15
Last Update Date:2011-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXG5490174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX159532401Medicaid
TX00350NMedicare PIN