Healthcare Provider Details

I. General information

NPI: 1528570884
Provider Name (Legal Business Name): CTMC, PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/26/2017
Last Update Date: 03/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10850 LOUETTA RD STE 1500
HOUSTON TX
77070-3537
US

IV. Provider business mailing address

PO BOX 5943
VIRGINIA BEACH VA
23471-0943
US

V. Phone/Fax

Practice location:
  • Phone: 281-320-2338
  • Fax: 281-320-2349
Mailing address:
  • Phone: 346-704-5400
  • Fax: 413-540-0159

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: SHAUN GILL
Title or Position: CEO
Credential:
Phone: 281-320-2338