Provider Demographics
NPI:1508015835
Name:MEDSTAR PRIMARY CARE CLINIC P.A.
Entity Type:Organization
Organization Name:MEDSTAR PRIMARY CARE CLINIC P.A.
Other - Org Name:MEDSTAR PRIMARY CARE CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:RACHEL
Authorized Official - Middle Name:CHUNDENU
Authorized Official - Last Name:KIENTCHA - TITA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:832-545-4614
Mailing Address - Street 1:14629 BEECHNUT ST
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77083-4436
Mailing Address - Country:US
Mailing Address - Phone:281-933-4447
Mailing Address - Fax:281-933-5557
Practice Address - Street 1:14629 BEECHNUT ST
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77083-4436
Practice Address - Country:US
Practice Address - Phone:281-933-4447
Practice Address - Fax:281-933-5557
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-09-10
Last Update Date:2008-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXM9410261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care