Basic Information
| Provider Information | |||||||||
| NPI: | 1275817504 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MEMORIAL HERMANN COMMUNITY BENEFIT CORPORATION | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | MEMORIAL HERMANN HEALTH CENTERS FOR SCHOOLS--WAVE CLINIC | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 909 FROSTWOOD DR | ||||||||
| Address2: | |||||||||
| City: | HOUSTON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 770242301 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7133385983 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1500 MAIN ST | ||||||||
| Address2: | |||||||||
| City: | SOUTH HOUSTON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 775874252 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7139467461 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/05/2011 | ||||||||
| LastUpdateDate: | 09/29/2022 | ||||||||
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| AuthorizedOfficialLastName: | PARET | ||||||||
| AuthorizedOfficialFirstName: | CAROL | ||||||||
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| AuthorizedOfficialTitleorPosition: | CHIEF COMMUNITY BENEFIT OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 7133385983 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 09/29/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | F0899 | TX | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine | 208000000X | F0889 | TX | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics | 261QP2300X | Y | Ambulatory Health Care Facilities | Clinic/Center | Primary Care |
No ID Information.