MEDICARE: MULTISPECIALTY CLINIC OF KINGWOOD 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

General Provider Information

NPI Number	:	1538427620
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MULTISPECIALTY CLINIC OF KINGWOOD LLC

Provider Business Mailing Address
First Line	:	25219 PINEGLEN TERRACE DR
Second Line	:
City	:	SPRING
State	:	TX
Zip	:	77389-4999
Country	:	US
Telephone Number	:	832-768-0703
Fax Number	:	832-717-6919

Provider Business Practice Location Address
First Line	:	25219 PINEGLEN TERRACE DR
Second Line	:
City	:	SPRING
State	:	TX
Zip	:	77389-4999
Country	:	US
Telephone Number	:	832-768-0703
Fax Number	:	832-717-6919

Authorized Official
Title or Position	:	OWNER
Name	:	MUSTAPHA KIBIRIGE
Credential	:	MD
Telephone Number	:	832-768-0703

Provider Enumeration Date	:	04/26/2012
Last Update Date	:	04/26/2012

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