Healthcare Provider Details

I. General information

NPI: 1285199448
Provider Name (Legal Business Name): INTERNIST CHRONIC CARE MANAGEMENT LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/01/2019
Last Update Date: 05/31/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

110 N CONCORD FOREST CIR
THE WOODLANDS TX
77381-6600
US

IV. Provider business mailing address

206 N 2100 W STE 202
SALT LAKE CITY UT
84116-4741
US

V. Phone/Fax

Practice location:
  • Phone: 281-836-3577
  • Fax: 801-883-8044
Mailing address:
  • Phone: 801-924-8571
  • Fax: 801-883-8044

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207RH0002X
TaxonomyHospice and Palliative Medicine (Internal Medicine) Physician
License Number
License Number State

VIII. Authorized Official

Name: THIMOS PASCHALIS
Title or Position: PHYSICIAN
Credential: MD
Phone: 281-836-3577