Provider Demographics
NPI:1679585772
Name:MEDICAL CENTER ENDOSCOPY, LLC
Entity Type:Organization
Organization Name:MEDICAL CENTER ENDOSCOPY, LLC
Other - Org Name:MEDICAL CENTER ENDOSCOPY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OFFICER AND AUTHORIZED OFFICIAL
Authorized Official - Prefix:
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:BOYD
Authorized Official - Last Name:BALDOCK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:615-234-5954
Mailing Address - Street 1:6560 FANNIN ST
Mailing Address - Street 2:SUITE 600
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77030-2761
Mailing Address - Country:US
Mailing Address - Phone:713-796-0500
Mailing Address - Fax:713-797-1417
Practice Address - Street 1:6560 FANNIN ST
Practice Address - Street 2:SUITE 600
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77030-2761
Practice Address - Country:US
Practice Address - Phone:713-796-0500
Practice Address - Fax:713-797-1417
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-13
Last Update Date:2022-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX0399261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXASC025OtherMEDICARE PTAN
TX45C0001238OtherMEDICARE PROVIDER #