Provider Demographics
NPI:1760781157
Name:NORTHSHORE MEDICAL ASSOCIATION PLLC
Entity Type:Organization
Organization Name:NORTHSHORE MEDICAL ASSOCIATION PLLC
Other - Org Name:NORTHSHORE MEDICAL ASSOCIATES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:DONALD
Authorized Official - Middle Name:R
Authorized Official - Last Name:HEARN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:281-457-2236
Mailing Address - Street 1:1140 WESTMONT DR
Mailing Address - Street 2:SUITE 202
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77015-4363
Mailing Address - Country:US
Mailing Address - Phone:281-457-2236
Mailing Address - Fax:281-457-0500
Practice Address - Street 1:1140 WESTMONT DR
Practice Address - Street 2:SUITE 202
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77015-4363
Practice Address - Country:US
Practice Address - Phone:281-457-2236
Practice Address - Fax:281-457-0500
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-03-24
Last Update Date:2016-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXH4392207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty