Provider Demographics
NPI:1295789337
Name:MEMORIAL MULTISPECIALTY ASSOCIATES
Entity type:Organization
Organization Name:MEMORIAL MULTISPECIALTY ASSOCIATES
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:C
Authorized Official - Last Name:ALLISON
Authorized Official - Suffix:III
Authorized Official - Credentials:
Authorized Official - Phone:713-798-1746
Mailing Address - Street 1:2 GREENWAY PLZ STE 900
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77046-0205
Mailing Address - Country:US
Mailing Address - Phone:713-798-1128
Mailing Address - Fax:
Practice Address - Street 1:8558 CREEKSIDE FOREST DR
Practice Address - Street 2:
Practice Address - City:THE WOODLANDS
Practice Address - State:TX
Practice Address - Zip Code:77375-2175
Practice Address - Country:US
Practice Address - Phone:713-798-1128
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-22
Last Update Date:2020-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
261QU0200X, 363LF0000X
TX564484363LA2100X
TXM1394174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty
Yes261QU0200XAmbulatory Health Care FacilitiesClinic/CenterUrgent CareGroup - Multi-Specialty
No363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute CareGroup - Multi-Specialty
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX0020BVOtherBLUE CROSS BLUE SHIELD
TX080151601Medicaid
TX0020BVMedicare PIN