Provider Demographics
NPI:1184707788
Name:MEMORIAL NW OTOLARYNGOLOGY HEAD & NECK SURGERY ASSOCIATES
Entity type:Organization
Organization Name:MEMORIAL NW OTOLARYNGOLOGY HEAD & NECK SURGERY ASSOCIATES
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:CONRAD
Authorized Official - Middle Name:KYLE
Authorized Official - Last Name:MCCUTCHEON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:281-822-3777
Mailing Address - Street 1:9055 KATY FWY
Mailing Address - Street 2:SUITE 415
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77024-1624
Mailing Address - Country:US
Mailing Address - Phone:281-822-3777
Mailing Address - Fax:281-822-3776
Practice Address - Street 1:9055 KATY FWY
Practice Address - Street 2:SUITE 415
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77024-1624
Practice Address - Country:US
Practice Address - Phone:281-822-3777
Practice Address - Fax:281-822-3776
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-24
Last Update Date:2021-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX00575UOtherBLUE CROSS BLUE SHIELD
TX00575UOtherBLUE CROSS BLUE SHIELD
=========OtherTIN