Provider Demographics
NPI:1710934419
Name:GRAINGER DIAGNOSTIC CLINIC, PA
Entity Type:Organization
Organization Name:GRAINGER DIAGNOSTIC CLINIC, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:HENRY
Authorized Official - Middle Name:JACK
Authorized Official - Last Name:GRAINGER
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:713-694-9709
Mailing Address - Street 1:511A W TIDWELL RD
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77091-4338
Mailing Address - Country:US
Mailing Address - Phone:713-694-9709
Mailing Address - Fax:
Practice Address - Street 1:511A W TIDWELL RD
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77091-4338
Practice Address - Country:US
Practice Address - Phone:713-694-9709
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-28
Last Update Date:2021-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXE1595207R00000X, 207RC0000X, 207RG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
No207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular DiseaseGroup - Single Specialty
No207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX165616701Medicaid
TX165616701Medicaid