Provider Demographics
NPI:1912461344
Name:INTRUST MEDICAL
Entity Type:Organization
Organization Name:INTRUST MEDICAL
Other - Org Name:INTRUST MEDICAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRACTICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:GENIA
Authorized Official - Middle Name:
Authorized Official - Last Name:MOORE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:346-907-5799
Mailing Address - Street 1:8240 ANTOINE DR STE 100
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77088-2534
Mailing Address - Country:US
Mailing Address - Phone:346-907-5799
Mailing Address - Fax:
Practice Address - Street 1:8240 ANTOINE DR STE 100
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77088-2534
Practice Address - Country:US
Practice Address - Phone:346-907-5799
Practice Address - Fax:346-907-5644
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-01-30
Last Update Date:2019-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Single Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty