Provider Demographics
NPI:1831483494
Name:NORTHWEST ENDO SURGICAL PLLC
Entity Type:Organization
Organization Name:NORTHWEST ENDO SURGICAL PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/ PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:MATTHEW
Authorized Official - Middle Name:J
Authorized Official - Last Name:ST. LAURENT
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:281-921-1890
Mailing Address - Street 1:18220 STATE HIGHWAY 249
Mailing Address - Street 2:STE. 300
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77070-4347
Mailing Address - Country:US
Mailing Address - Phone:281-921-1890
Mailing Address - Fax:281-921-1897
Practice Address - Street 1:18220 STATE HIGHWAY 249
Practice Address - Street 2:STE. 300
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77070-4347
Practice Address - Country:US
Practice Address - Phone:281-921-1890
Practice Address - Fax:281-921-1897
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-06-01
Last Update Date:2011-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXJ4536208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Multi-Specialty