Provider Demographics
NPI:1669412250
Name:PREMIER HOUSTON AREA FAMILY MEDICAL CLINICS
Entity type:Organization
Organization Name:PREMIER HOUSTON AREA FAMILY MEDICAL CLINICS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING
Authorized Official - Prefix:MS
Authorized Official - First Name:MARIE
Authorized Official - Middle Name:D
Authorized Official - Last Name:MENGARELLI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:713-946-6081
Mailing Address - Street 1:2211 A E. BROADWAY
Mailing Address - Street 2:
Mailing Address - City:PEARLAND
Mailing Address - State:TX
Mailing Address - Zip Code:77581
Mailing Address - Country:US
Mailing Address - Phone:281-485-6144
Mailing Address - Fax:281-485-6146
Practice Address - Street 1:2211 A E. BROADWAY
Practice Address - Street 2:
Practice Address - City:PEARLAND
Practice Address - State:TX
Practice Address - Zip Code:77581
Practice Address - Country:US
Practice Address - Phone:281-485-6144
Practice Address - Fax:281-485-6146
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-08
Last Update Date:2010-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXF5827207RC0000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular DiseaseGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX080069001Medicaid
TX00174NMedicare PIN