Provider Demographics
NPI:1982119061
Name:ELITE HEART, LUNG, AND VEIN SURGEONS
Entity Type:Organization
Organization Name:ELITE HEART, LUNG, AND VEIN SURGEONS
Other - Org Name:ELITE HEART, LUNG, AND VEIN SURGEONS
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:PRACTICE ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:LACEY
Authorized Official - Middle Name:
Authorized Official - Last Name:BUFORD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:936-648-6975
Mailing Address - Street 1:920 MEDICAL PLAZA DR STE 360
Mailing Address - Street 2:
Mailing Address - City:SHENANDOAH
Mailing Address - State:TX
Mailing Address - Zip Code:77380-3271
Mailing Address - Country:US
Mailing Address - Phone:281-803-8482
Mailing Address - Fax:281-803-8432
Practice Address - Street 1:920 MEDICAL PLAZA DR STE 360
Practice Address - Street 2:
Practice Address - City:SHENANDOAH
Practice Address - State:TX
Practice Address - Zip Code:77380-3271
Practice Address - Country:US
Practice Address - Phone:281-803-8482
Practice Address - Fax:281-803-8432
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-12-11
Last Update Date:2021-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXL1655208G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208G00000XAllopathic & Osteopathic PhysiciansThoracic Surgery (Cardiothoracic Vascular Surgery)Group - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX145174210Medicaid