MEDICARE: NORTHSIDE MEDICAL CLINIC LLC

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	207Q00000X	Family Medicine Physician		TX

General Provider Information

NPI Number	:	1487926978
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	NORTHSIDE MEDICAL CLINIC LLC

Provider Business Mailing Address
First Line	:	4414 NORTH FWY STE 800
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77022-3662
Country	:	US
Telephone Number	:	713-692-4200
Fax Number	:	713-692-2253

Provider Business Practice Location Address
First Line	:	13211 WINDFERN RD STE C
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77064-3096
Country	:	US
Telephone Number	:	281-477-7144
Fax Number	:	281-477-7448

Authorized Official
Title or Position	:	ADMINISTRATOR
Name	:	JOSE I GONZALEZ
Credential	:
Telephone Number	:	281-477-7144

Provider Enumeration Date	:	01/31/2012
Last Update Date	:	01/31/2012

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