Provider Demographics
NPI:1457574006
Name:GREATER GULF HEALTH PLAN, LLC
Entity Type:Organization
Organization Name:GREATER GULF HEALTH PLAN, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:LAWRENCE
Authorized Official - Middle Name:J
Authorized Official - Last Name:WEDEKIND
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:281-447-6800
Mailing Address - Street 1:260 N SAM HOUSTON PKWY E
Mailing Address - Street 2:SUITE 220
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77060-2018
Mailing Address - Country:US
Mailing Address - Phone:281-447-6800
Mailing Address - Fax:281-447-6802
Practice Address - Street 1:260 N SAM HOUSTON PKWY E STE 220
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77060-2022
Practice Address - Country:US
Practice Address - Phone:281-447-6800
Practice Address - Fax:281-447-6802
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-11
Last Update Date:2008-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX01486663208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX176768301Medicaid
TX176768302Medicaid
TX00690KOtherBCBS ID
TX00690KMedicare PIN