Provider Demographics
NPI:1770677130
Name:MEDICAL INFECTIOUS DISEASE CONSULTING SERVICE
Entity Type:Organization
Organization Name:MEDICAL INFECTIOUS DISEASE CONSULTING SERVICE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:RICARDO
Authorized Official - Middle Name:
Authorized Official - Last Name:BOLIVAR
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:281-893-4376
Mailing Address - Street 1:PO BOX 131224
Mailing Address - Street 2:
Mailing Address - City:THE WOODLANDS
Mailing Address - State:TX
Mailing Address - Zip Code:77393
Mailing Address - Country:US
Mailing Address - Phone:281-893-4376
Mailing Address - Fax:281-419-6362
Practice Address - Street 1:18951 N MEMORIAL
Practice Address - Street 2:
Practice Address - City:HUMBLE
Practice Address - State:TX
Practice Address - Zip Code:77338-4217
Practice Address - Country:US
Practice Address - Phone:281-540-7700
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-02
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXE7377207RI0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious DiseaseGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX00L17PMedicare ID - Type Unspecified
TXE04557Medicare UPIN