Provider Demographics
NPI:1275600751
Name:RENAISSANCE SURGICAL CENTER-NORTHEAST, L.L.P
Entity Type:Organization
Organization Name:RENAISSANCE SURGICAL CENTER-NORTHEAST, L.L.P
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MUSTAPHA
Authorized Official - Middle Name:
Authorized Official - Last Name:KIBIRIGE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:713-532-7311
Mailing Address - Street 1:PO BOX 669
Mailing Address - Street 2:
Mailing Address - City:HUMBLE
Mailing Address - State:TX
Mailing Address - Zip Code:77347-0669
Mailing Address - Country:US
Mailing Address - Phone:713-532-7311
Mailing Address - Fax:713-532-7359
Practice Address - Street 1:18929 HIGHWAY 59 N
Practice Address - Street 2:
Practice Address - City:HUMBLE
Practice Address - State:TX
Practice Address - Zip Code:77338-4270
Practice Address - Country:US
Practice Address - Phone:713-532-7311
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-29
Last Update Date:2018-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX261QA1903X261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXHH1370OtherBCBS GRP #
TX1586968-01Medicaid
TXHH1370OtherBCBS GRP #