Provider Demographics
NPI:1477958940
Name:ARCHANGEL MEDICAL LLC
Entity Type:Organization
Organization Name:ARCHANGEL MEDICAL LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:CHERYL
Authorized Official - Middle Name:KAREN
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:832-387-6000
Mailing Address - Street 1:6630 HORNWOOD DR
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77074-5010
Mailing Address - Country:US
Mailing Address - Phone:832-387-6000
Mailing Address - Fax:
Practice Address - Street 1:6630 HORNWOOD DR
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77074-5010
Practice Address - Country:US
Practice Address - Phone:832-378-6000
Practice Address - Fax:832-648-4626
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-10-27
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
207Q00000X
TX261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No261Q00000XAmbulatory Health Care FacilitiesClinic/CenterGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX353328301Medicaid