Provider Demographics
NPI:1013303858
Name:PRIME RHEUMATOLOGY CLINIC OF HOUSTON PLLC
Entity Type:Organization
Organization Name:PRIME RHEUMATOLOGY CLINIC OF HOUSTON PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SOLE MBR
Authorized Official - Prefix:
Authorized Official - First Name:GWENDOLINE
Authorized Official - Middle Name:
Authorized Official - Last Name:MENGA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:832-821-5550
Mailing Address - Street 1:17191 ST LUKES WAY
Mailing Address - Street 2:STE 220
Mailing Address - City:THE WOODLANDS
Mailing Address - State:TX
Mailing Address - Zip Code:77384-8042
Mailing Address - Country:US
Mailing Address - Phone:832-821-5550
Mailing Address - Fax:936-207-4109
Practice Address - Street 1:17191 ST LUKES WAY
Practice Address - Street 2:STE 220
Practice Address - City:THE WOODLANDS
Practice Address - State:TX
Practice Address - Zip Code:77384-8042
Practice Address - Country:US
Practice Address - Phone:832-821-5550
Practice Address - Fax:936-207-4109
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-04-08
Last Update Date:2015-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXN8040207RR0500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RR0500XAllopathic & Osteopathic PhysiciansInternal MedicineRheumatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXDV7370OtherRR MEDICARE
TXDV7370OtherRR MEDICARE