Basic Information
Provider Information | |||||||||
NPI: | 1255430690 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | BAYLOR COLLEGE OF MEDICINE | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | HCHD PATHOLOGY | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 2 E GREENWAY PLZ | ||||||||
Address2: | SUITE 900 | ||||||||
City: | HOUSTON | ||||||||
State: | TX | ||||||||
PostalCode: | 770460297 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7137981835 | ||||||||
FaxNumber: | 7137981144 | ||||||||
Practice Location | |||||||||
Address1: | 1504 TAUB LOOP | ||||||||
Address2: | DEPT. OF PATHOLOGY | ||||||||
City: | HOUSTON | ||||||||
State: | TX | ||||||||
PostalCode: | 770301608 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7138733200 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 09/22/2006 | ||||||||
LastUpdateDate: | 02/06/2009 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | NICKENS | ||||||||
AuthorizedOfficialFirstName: | JOHN | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | EXECUTIVE DIRECTOR | ||||||||
AuthorizedOfficialTelephone: | 7137981710 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207ZP0101X |   |   | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pathology | Anatomic Pathology |
ID Information
ID | Type | State | Issuer | Description | 112556901 | 05 | TX |   | MEDICAID |