Provider Demographics
NPI:1518065150
Name:MONTGOMERY COUNTY LUNG CLINIC, P.A.
Entity Type:Organization
Organization Name:MONTGOMERY COUNTY LUNG CLINIC, P.A.
Other - Org Name:NONE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:EDWARD
Authorized Official - Middle Name:M
Authorized Official - Last Name:FLORES
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:936-756-2488
Mailing Address - Street 1:110 COMMERCIAL CIR
Mailing Address - Street 2:
Mailing Address - City:CONROE
Mailing Address - State:TX
Mailing Address - Zip Code:77304-2204
Mailing Address - Country:US
Mailing Address - Phone:936-756-2488
Mailing Address - Fax:936-756-3686
Practice Address - Street 1:110 COMMERCIAL CIR
Practice Address - Street 2:
Practice Address - City:CONROE
Practice Address - State:TX
Practice Address - Zip Code:77304-2204
Practice Address - Country:US
Practice Address - Phone:936-756-2488
Practice Address - Fax:936-756-3686
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-20
Last Update Date:2011-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary DiseaseGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX093928201Medicaid
TXZ000F63EMedicare PIN