MEDICARE: MARION LADEWIG OPAC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363AS0400X	Surgical Physician Assistant	0817	TX

General Provider Information

NPI Number	:	1326024522
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARION LADEWIG OPAC

Provider Business Mailing Address
First Line	:	7401 MAIN ST
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77030-4509
Country	:	US
Telephone Number	:	713-794-3338
Fax Number	:	713-794-3395

Provider Business Practice Location Address
First Line	:	900 ROCKMEAD DR
Second Line	:
City	:	HUMBLE
State	:	TX
Zip	:	77339-2115
Country	:	US
Telephone Number	:	281-359-5115
Fax Number	:	281-359-2663

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/20/2005
Last Update Date	:	07/08/2007

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