MEDICARE: PASADENA COMMUNITY HEALTH GROUP 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	207PE0004X	Emergency Medical Services (Emergency Medicine) Physician	J6641	TX
2	207QG0300X	Geriatric Medicine (Family Medicine) Physician	J6641	TX
3	208D00000X	General Practice Physician	J6641	TX

General Provider Information

NPI Number	:	1841509395
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PASADENA COMMUNITY HEALTH GROUP LLC

Provider Business Mailing Address
First Line	:	4002 BURKE RD
Second Line	:
City	:	PASADENA
State	:	TX
Zip	:	77504-3451
Country	:	US
Telephone Number	:	281-606-2020
Fax Number	:	281-606-2021

Provider Business Practice Location Address
First Line	:	4002 BURKE RD
Second Line	:
City	:	PASADENA
State	:	TX
Zip	:	77504-3451
Country	:	US
Telephone Number	:	281-606-2020
Fax Number	:	281-606-2021

Authorized Official
Title or Position	:	PRESIDENT
Name	:	MR. STANTON PACKARD
Credential	:	M.D.
Telephone Number	:	281-606-2020

Provider Enumeration Date	:	10/01/2010
Last Update Date	:	10/01/2010

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