Provider Demographics
NPI:1265474597
Name:JACINTO MEDICAL GROUP P A
Entity Type:Organization
Organization Name:JACINTO MEDICAL GROUP P A
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING COORDINATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:MAGGIE
Authorized Official - Middle Name:
Authorized Official - Last Name:KHAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:281-425-3844
Mailing Address - Street 1:2800 GARTH RD
Mailing Address - Street 2:
Mailing Address - City:BAYTOWN
Mailing Address - State:TX
Mailing Address - Zip Code:77521-3947
Mailing Address - Country:US
Mailing Address - Phone:281-425-3800
Mailing Address - Fax:281-425-3992
Practice Address - Street 1:2800 GARTH RD
Practice Address - Street 2:
Practice Address - City:BAYTOWN
Practice Address - State:TX
Practice Address - Zip Code:77521-3947
Practice Address - Country:US
Practice Address - Phone:281-425-3800
Practice Address - Fax:281-425-3992
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-12
Last Update Date:2012-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX816738-03207Q00000X, 207R00000X, 207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX00U80BOtherBCBS
TX085781501Medicaid
TXU80BMedicare ID - Type Unspecified
TX085781501Medicaid