Provider Demographics
NPI:1861681009
Name:WELLSPRING CARDIOVASCULAR & THORACIC SURGERY, PA
Entity Type:Organization
Organization Name:WELLSPRING CARDIOVASCULAR & THORACIC SURGERY, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:CORNELIUS
Authorized Official - Middle Name:ALEXANDER
Authorized Official - Last Name:DAVIS
Authorized Official - Suffix:III
Authorized Official - Credentials:MD
Authorized Official - Phone:713-795-4545
Mailing Address - Street 1:PO BOX 20056
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77225-0056
Mailing Address - Country:US
Mailing Address - Phone:713-795-4545
Mailing Address - Fax:713-795-4595
Practice Address - Street 1:6400 FANNIN ST
Practice Address - Street 2:STE. 2500
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77030-1521
Practice Address - Country:US
Practice Address - Phone:713-795-4545
Practice Address - Fax:713-795-4595
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-23
Last Update Date:2011-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXL7349208G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208G00000XAllopathic & Osteopathic PhysiciansThoracic Surgery (Cardiothoracic Vascular Surgery)Group - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1528037975OtherINDIVIDUAL NPI
TX1653768-01Medicaid
TX00860VMedicare PIN