MEDICARE: FORT BEND INTERNAL MEDICINE AND PEDIATRICS, P.A.

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	208000000X	Pediatrics Physician	L7205	TX
2	207R00000X	Internal Medicine Physician	L7205	TX

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	0094PD	OTHER	TX	BC BS PROVIDER NUMBER

General Provider Information

NPI Number	:	1477604775
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	FORT BEND INTERNAL MEDICINE AND PEDIATRICS, P.A.

Provider Business Mailing Address
First Line	:	PO BOX 17295
Second Line	:
City	:	SUGAR LAND
State	:	TX
Zip	:	77496-7295
Country	:	US
Telephone Number	:	281-208-1908
Fax Number	:	281-208-1930

Provider Business Practice Location Address
First Line	:	4646 RIVERSTONE BLVD
Second Line	:
City	:	MISSOURI CITY
State	:	TX
Zip	:	77459-6141
Country	:	US
Telephone Number	:	281-208-1908
Fax Number	:

Authorized Official
Title or Position	:	PHYSICIAN
Name	:	DR. HARI KRISHNA SUSARLA
Credential	:	M.D.
Telephone Number	:	281-208-1908

Provider Enumeration Date	:	01/15/2007
Last Update Date	:	07/25/2008

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