Healthcare Provider Details

I. General information

NPI: 1790125268
Provider Name (Legal Business Name): TIMBER LOOP EMERGENCY PHYSICIANS, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/28/2013
Last Update Date: 07/02/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

504 MEDICAL CENTER BLVD
CONROE TX
77304-2808
US

IV. Provider business mailing address

PO BOX 98786
LAS VEGAS NV
89193
US

V. Phone/Fax

Practice location:
  • Phone: 936-539-1111
  • Fax:
Mailing address:
  • Phone: 800-507-8874
  • Fax: 727-536-2896

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: GREGORY J. BYRNE
Title or Position: PRESIDENT
Credential: M.D.
Phone: 800-507-8874