Provider Demographics
NPI:1912448903
Name:CALVARY MED PA
Entity Type:Organization
Organization Name:CALVARY MED PA
Other - Org Name:CALVARY HUMBLE LAB
Other - Org Type:Other Name
Authorized Official - Title/Position:OWNER/MEDICAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:JOSEPH
Authorized Official - Middle Name:
Authorized Official - Last Name:GOIN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:832-680-2273
Mailing Address - Street 1:8484 WILL CLAYTON PKWY
Mailing Address - Street 2:
Mailing Address - City:HUMBLE
Mailing Address - State:TX
Mailing Address - Zip Code:77338-5830
Mailing Address - Country:US
Mailing Address - Phone:832-680-2273
Mailing Address - Fax:832-995-5219
Practice Address - Street 1:8484 WILL CLAYTON PKWY
Practice Address - Street 2:
Practice Address - City:HUMBLE
Practice Address - State:TX
Practice Address - Zip Code:77338-5830
Practice Address - Country:US
Practice Address - Phone:832-680-2273
Practice Address - Fax:832-995-5219
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CALVARY MED PA
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2017-03-10
Last Update Date:2017-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXK5963291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1730189408Medicare UPIN