Provider Demographics
NPI:1457441503
Name:GARY R. MENNIE, M.D.
Entity Type:Organization
Organization Name:GARY R. MENNIE, M.D.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:GARY
Authorized Official - Middle Name:ROY
Authorized Official - Last Name:MENNIE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:409-727-4642
Mailing Address - Street 1:2770 AERO DRIVE
Mailing Address - Street 2:SUITE 1
Mailing Address - City:PORT ARTHUR
Mailing Address - State:TX
Mailing Address - Zip Code:77640
Mailing Address - Country:US
Mailing Address - Phone:409-727-4642
Mailing Address - Fax:409-721-9774
Practice Address - Street 1:2770 AERO DRIVE
Practice Address - Street 2:SUITE 1
Practice Address - City:PORT ARTHUR
Practice Address - State:TX
Practice Address - Zip Code:77640
Practice Address - Country:US
Practice Address - Phone:409-727-4642
Practice Address - Fax:409-721-9774
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-12
Last Update Date:2008-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXK9128174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
G85976Medicare UPIN
TX00033XMedicare PIN