Provider Demographics
NPI:1669956942
Name:PROVENTIAL MEDICAL GROUP
Entity type:Organization
Organization Name:PROVENTIAL MEDICAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:
Authorized Official - Last Name:FILLEY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:281-543-0012
Mailing Address - Street 1:10507 E WILDWIND CIR
Mailing Address - Street 2:
Mailing Address - City:SPRING
Mailing Address - State:TX
Mailing Address - Zip Code:77380-4043
Mailing Address - Country:US
Mailing Address - Phone:281-543-0012
Mailing Address - Fax:281-605-4566
Practice Address - Street 1:21300 PROVINCIAL BLVD
Practice Address - Street 2:SUITE 200
Practice Address - City:KATY
Practice Address - State:TX
Practice Address - Zip Code:77450
Practice Address - Country:US
Practice Address - Phone:713-562-7890
Practice Address - Fax:281-605-4566
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-09-21
Last Update Date:2018-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain MedicineGroup - Single Specialty