Healthcare Provider Details

I. General information

NPI: 1295068187
Provider Name (Legal Business Name): MEDINA MEDICAL CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/10/2009
Last Update Date: 09/10/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 N TEEL DR STE 105
DEVINE TX
78016-2650
US

IV. Provider business mailing address

17510 W GRAND PKWY S STE 410
SUGAR LAND TX
77479-2645
US

V. Phone/Fax

Practice location:
  • Phone: 830-663-3500
  • Fax: 830-663-3505
Mailing address:
  • Phone: 281-232-9772
  • Fax: 281-232-3885

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RN0300X
TaxonomyNephrology Physician
License NumberK1960
License Number StateTX

VIII. Authorized Official

Name: MRS. SHAHNAZ SIDHWA
Title or Position: OFFICE MANAGER
Credential:
Phone: 281-232-9772