Provider Demographics
NPI:1699024158
Name:MICHAEL J BADLISSI MD PA
Entity Type:Organization
Organization Name:MICHAEL J BADLISSI MD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MD/ PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:BADLISSI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:409-727-7342
Mailing Address - Street 1:2300 HIGHWAY 365 STE 330
Mailing Address - Street 2:
Mailing Address - City:NEDERLAND
Mailing Address - State:TX
Mailing Address - Zip Code:77627-6255
Mailing Address - Country:US
Mailing Address - Phone:409-727-7342
Mailing Address - Fax:
Practice Address - Street 1:2300 HIGHWAY 365 STE 330
Practice Address - Street 2:
Practice Address - City:NEDERLAND
Practice Address - State:TX
Practice Address - Zip Code:77627-6255
Practice Address - Country:US
Practice Address - Phone:409-727-7342
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-08-30
Last Update Date:2021-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXP3115207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1770710337OtherTYPE 1 NPI