Healthcare Provider Details

I. General information

NPI: 1518219104
Provider Name (Legal Business Name): EAST HOUSTON PHYSICIANS GROUP, PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/08/2012
Last Update Date: 06/27/2024
Certification Date: 06/27/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11821 EAST FWY STE 175
HOUSTON TX
77029-1960
US

IV. Provider business mailing address

PO BOX 96706
HOUSTON TX
77213-6706
US

V. Phone/Fax

Practice location:
  • Phone: 713-330-0766
  • Fax: 877-862-8370
Mailing address:
  • Phone: 713-330-0766
  • Fax: 713-330-0794

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. RONALD WAYNE KILLAM
Title or Position: CEO
Credential: MD
Phone: 713-330-0766