Healthcare Provider Details

I. General information

NPI: 1992802425
Provider Name (Legal Business Name): SOUTHEAST TEXAS HYPERBARIC MEDICINE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/19/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

500 MEDICAL CENTER BLVD STE 110
CONROE TX
77304-2800
US

IV. Provider business mailing address

PO BOX 988
CONROE TX
77305-0988
US

V. Phone/Fax

Practice location:
  • Phone: 936-539-7034
  • Fax:
Mailing address:
  • Phone: 936-539-7034
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License NumberG5492
License Number StateTX

VIII. Authorized Official

Name: DR. BRADLEY A PONTANI
Title or Position: PHYSICIAN/OWNER
Credential: M.D.
Phone: 936-539-7034