Healthcare Provider Details

I. General information

NPI: 1962676122
Provider Name (Legal Business Name): NORTHEAST HOUSTON SPINE CENTER PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/18/2008
Last Update Date: 09/19/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14450 T.C. JESTER SUITE 100
HOUSTON TX
77014-1331
US

IV. Provider business mailing address

PO BOX 132618
THE WOODLANDS TX
77393-2618
US

V. Phone/Fax

Practice location:
  • Phone: 281-292-1121
  • Fax: 832-553-3211
Mailing address:
  • Phone: 281-292-1121
  • Fax: 832-553-3211

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207XS0117X
TaxonomyOrthopaedic Surgery of the Spine Physician
License NumberM0921
License Number StateTX

VIII. Authorized Official

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