Healthcare Provider Details

I. General information

NPI: 1568691327
Provider Name (Legal Business Name): CHAMPIONS SPINE CENTER PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/14/2009
Last Update Date: 05/19/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14450 TC JESTER BLVD. SUITE 100
HOUSTON TX
77014
US

IV. Provider business mailing address

14450 TC JESTER BLVD. SUITE 100
HOUSTON TX
77014
US

V. Phone/Fax

Practice location:
  • Phone: 281-292-1121
  • Fax:
Mailing address:
  • Phone: 281-292-1121
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberN3996
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code207XS0117X
TaxonomyOrthopaedic Surgery of the Spine Physician
License NumberM9431
License Number StateTX

VIII. Authorized Official

Name: DR. SAQIB A SIDDIQUI
Title or Position: MD/PRESIDENT
Credential: M.D.
Phone: 281-292-1121