Basic Information
| Provider Information | |||||||||
| NPI: | 1508930181 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | BAYLOR COLLEGE OF MEDICINE | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
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| OtherOrganizationName: | AMS BAYLOR - HCHD CARDIOLOGY | ||||||||
| 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: | 7137981835 | ||||||||
| FaxNumber: | 7137981144 | ||||||||
| Practice Location | |||||||||
| Address1: | 1504 TAUB LOOP | ||||||||
| Address2: | DEPT. OF CARDIOLOGY | ||||||||
| City: | HOUSTON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 770301608 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7138738631 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 11/17/2006 | ||||||||
| LastUpdateDate: | 06/19/2008 | ||||||||
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| AuthorizedOfficialLastName: | NICKENS | ||||||||
| AuthorizedOfficialFirstName: | JOHN | ||||||||
| AuthorizedOfficialMiddleName: | R. | ||||||||
| AuthorizedOfficialTitleorPosition: | EXECUTIVE DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 7137981710 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RC0000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease |
ID Information
| ID | Type | State | Issuer | Description | 093665001 | 05 | TX | MEDICAID |