Provider Demographics
NPI:1134167653
Name:PROFESSIONAL MEDICAL & SURGICAL CLINIC ASSOCIATION
Entity type:Organization
Organization Name:PROFESSIONAL MEDICAL & SURGICAL CLINIC ASSOCIATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:CHRISTOPHER
Authorized Official - Middle Name:S
Authorized Official - Last Name:ANGELO
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:713-863-1555
Mailing Address - Street 1:1740 W 27TH ST #221
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77008
Mailing Address - Country:US
Mailing Address - Phone:713-863-1555
Mailing Address - Fax:
Practice Address - Street 1:1740 W 27TH ST
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77008-1433
Practice Address - Country:US
Practice Address - Phone:713-863-1555
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-04
Last Update Date:2014-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXD5589207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8A1910OtherBCBS
TX103693101Medicaid
TX103693101Medicaid
TX00W304Medicare ID - Type Unspecified