Provider Demographics
NPI:1548560428
Name:GREENWAY PLAZA ENT CLINIC INC
Entity Type:Organization
Organization Name:GREENWAY PLAZA ENT CLINIC INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDEN/BUSINESS DEVELOPMENT
Authorized Official - Prefix:
Authorized Official - First Name:OMAR
Authorized Official - Middle Name:
Authorized Official - Last Name:FUSTOK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:713-621-2558
Mailing Address - Street 1:4140 SOUTHWEST FWY STE 510
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77027-7319
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4140 SOUTHWEST FWY STE 510
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77027-7319
Practice Address - Country:US
Practice Address - Phone:813-621-2558
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-10-26
Last Update Date:2010-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty