Healthcare Provider Details

I. General information

NPI: 1861689481
Provider Name (Legal Business Name): CISCO SURGICAL, PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/27/2007
Last Update Date: 09/27/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4120 SOUTHWEST FWY 200
HOUSTON TX
77027-7339
US

IV. Provider business mailing address

PO BOX 1759 DEPT 757
HOUSTON TX
77251-1759
US

V. Phone/Fax

Practice location:
  • Phone: 713-355-8600
  • Fax: 713-355-8069
Mailing address:
  • Phone: 713-355-8600
  • Fax: 713-355-8069

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA1903X
TaxonomyAmbulatory Surgical Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: JODIE R ELLIS
Title or Position: BUSINESS OFFICE SUPERVISOR
Credential:
Phone: 713-355-8600