Provider Demographics
NPI:1245410018
Name:ANDREW B CIVITELLO MD PA
Entity Type:Organization
Organization Name:ANDREW B CIVITELLO MD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:ALICE
Authorized Official - Middle Name:CATHY
Authorized Official - Last Name:CIVITELLO
Authorized Official - Suffix:
Authorized Official - Credentials:PA-C
Authorized Official - Phone:713-526-8900
Mailing Address - Street 1:1200 BINZ ST
Mailing Address - Street 2:SUITE 1290
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77004-6900
Mailing Address - Country:US
Mailing Address - Phone:713-526-8900
Mailing Address - Fax:713-526-8901
Practice Address - Street 1:1200 BINZ ST
Practice Address - Street 2:SUITE 1290
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77004-6900
Practice Address - Country:US
Practice Address - Phone:713-526-8900
Practice Address - Fax:713-526-8901
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-09
Last Update Date:2010-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXK4661207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular DiseaseGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX191438401Medicaid
TX191438401Medicaid