Healthcare Provider Details

I. General information

NPI: 1841509395
Provider Name (Legal Business Name): PASADENA COMMUNITY HEALTH GROUP LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/01/2010
Last Update Date: 10/01/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4002 BURKE RD
PASADENA TX
77504-3451
US

IV. Provider business mailing address

4002 BURKE RD
PASADENA TX
77504-3451
US

V. Phone/Fax

Practice location:
  • Phone: 281-606-2020
  • Fax: 281-606-2021
Mailing address:
  • Phone: 281-606-2020
  • Fax: 281-606-2021

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207PE0004X
TaxonomyEmergency Medical Services (Emergency Medicine) Physician
License NumberJ6641
License Number StateTX
# 2
Primary TaxonomyN
Taxonomy Code207QG0300X
TaxonomyGeriatric Medicine (Family Medicine) Physician
License NumberJ6641
License Number StateTX
# 3
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License NumberJ6641
License Number StateTX

VIII. Authorized Official

Name: MR. STANTON PACKARD
Title or Position: PRESIDENT
Credential: M.D.
Phone: 281-606-2020