Basic Information
| Provider Information | |||||||||
| NPI: | 1972516557 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | BAYLOR COLLEGE OF MEDICINE | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
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| OtherOrganizationName: | DEPARTMENT OF OBSTETRICS AND GYNECOLOGY | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 4775 | ||||||||
| Address2: | |||||||||
| City: | HOUSTON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 772104775 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7137985696 | ||||||||
| FaxNumber: | 7137981144 | ||||||||
| Practice Location | |||||||||
| Address1: | 6620 MAIN ST | ||||||||
| Address2: | SUITE 1450 | ||||||||
| City: | HOUSTON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 770302348 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7137987500 | ||||||||
| FaxNumber: | 7137986956 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/14/2006 | ||||||||
| LastUpdateDate: | 11/01/2007 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | NICKENS | ||||||||
| AuthorizedOfficialFirstName: | JOHN | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | DEPARTMENT ADMINISTRATOR | ||||||||
| AuthorizedOfficialTelephone: | 7137981714 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207V00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology |
No ID Information.