Provider Demographics
NPI:1235312000
Name:MEDSOURCE
Entity Type:Organization
Organization Name:MEDSOURCE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:SYLVIA
Authorized Official - Middle Name:
Authorized Official - Last Name:BOARDS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:713-532-7311
Mailing Address - Street 1:1630 HILTON HEAD DR
Mailing Address - Street 2:
Mailing Address - City:MISSOURI CITY
Mailing Address - State:TX
Mailing Address - Zip Code:77459-3420
Mailing Address - Country:US
Mailing Address - Phone:713-532-7311
Mailing Address - Fax:713-532-7399
Practice Address - Street 1:1630 HILTON HEAD DR
Practice Address - Street 2:
Practice Address - City:MISSOURI CITY
Practice Address - State:TX
Practice Address - Zip Code:77459-3420
Practice Address - Country:US
Practice Address - Phone:713-532-7311
Practice Address - Fax:713-532-7399
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-14
Last Update Date:2007-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX007971261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical