Healthcare Provider Details

I. General information

NPI: 1922491448
Provider Name (Legal Business Name): PEDIATRIC CARDIOLOGY CARE PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/09/2015
Last Update Date: 03/09/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

711 W BAY AREA BLVD SUITE 625
WEBSTER TX
77598-4043
US

IV. Provider business mailing address

711 W BAY AREA BLVD SUITE 625
WEBSTER TX
77598-4043
US

V. Phone/Fax

Practice location:
  • Phone: 281-648-3000
  • Fax: 281-648-3001
Mailing address:
  • Phone: 281-648-3000
  • Fax: 281-648-3001

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080P0202X
TaxonomyPediatric Cardiology Physician
License Number
License Number StateTX

VIII. Authorized Official

Name: TAL GOSPIN
Title or Position: PRESIDENT
Credential: M.D.
Phone: 281-648-3000