Provider Demographics
NPI:1639353121
Name:LIVER, KIDNEY AND INTERNAL MEDICINE CENTER
Entity Type:Organization
Organization Name:LIVER, KIDNEY AND INTERNAL MEDICINE CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:BRYAN
Authorized Official - Middle Name:C
Authorized Official - Last Name:LIPSEN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:713-635-6996
Mailing Address - Street 1:509 W TIDWELL RD STE 314
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77091-4354
Mailing Address - Country:US
Mailing Address - Phone:713-635-6996
Mailing Address - Fax:713-635-6994
Practice Address - Street 1:509 W TIDWELL RD
Practice Address - Street 2:SUITE 314
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77091-4352
Practice Address - Country:US
Practice Address - Phone:713-635-6996
Practice Address - Fax:713-635-9694
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:LIVER, KIDNEY AND INTERNAL MEDICINE CENTER
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-12-20
Last Update Date:2021-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX171704302Medicaid
TX00978XMedicare PIN
TX171704302Medicaid