Basic Information
| Provider Information | |||||||||
| NPI: | 1386691681 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | BAYLOR COLLEGE OF MEDICINE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2 E GREENWAY PLZ | ||||||||
| Address2: | SUITE 900 | ||||||||
| City: | HOUSTON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 770460297 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7137981750 | ||||||||
| FaxNumber: | 7137981144 | ||||||||
| Practice Location | |||||||||
| Address1: | 6701 FANNIN ST | ||||||||
| Address2: | |||||||||
| City: | HOUSTON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 770302316 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8328221000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/30/2006 | ||||||||
| LastUpdateDate: | 01/26/2018 | ||||||||
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| AuthorizedOfficialLastName: | ALLISON | ||||||||
| AuthorizedOfficialFirstName: | RICHARD | ||||||||
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| AuthorizedOfficialTitleorPosition: | EXECUTIVE DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 7137981746 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | III | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 136324405 | 05 | TX | MEDICAID |