Basic Information
| Provider Information | |||||||||
| NPI: | 1295769107 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | BAYLOR COLLEGE OF MEDICINE | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | HCHD SURGERY | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2 E GREENWAY PLZ | ||||||||
| Address2: | SUITE 900 | ||||||||
| City: | HOUSTON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 770460297 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7137981710 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1504 TAUB LOOP | ||||||||
| Address2: | |||||||||
| City: | HOUSTON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 770301608 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7138732000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/10/2006 | ||||||||
| LastUpdateDate: | 02/06/2009 | ||||||||
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| AuthorizedOfficialLastName: | NICKENS | ||||||||
| AuthorizedOfficialFirstName: | JOHN | ||||||||
| AuthorizedOfficialMiddleName: | R. | ||||||||
| AuthorizedOfficialTitleorPosition: | EXECUTIVE DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 7137981710 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208600000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Surgery |
ID Information
| ID | Type | State | Issuer | Description | 093732801 | 05 | TX | MEDICAID |