=====================================================
General NPI Number Information
=====================================================
NPI Number | 1093109167
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | COLBERT PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/26/2015
-----------------------------------------------------
Last Update Date | 03/26/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 6121 HILLCROFT ST # 0
-----------------------------------------------------
City | HOUSTON
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77081-1002
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 713-541-0064
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 6121 HILLCROFT ST STE 0
-----------------------------------------------------
City | HOUSTON
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77081-1002
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 713-541-0064
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MEDICAL DIRECTOR
-----------------------------------------------------
Name | CHRISTLE COLBERT
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 713-541-0064
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207LP2900X
-----------------------------------------------------
Taxonomy Name | Pain Medicine (Anesthesiology) Physician
-----------------------------------------------------
License Number | P1533
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 2081P2900X
-----------------------------------------------------
Taxonomy Name | Pain Medicine (Physical Medicine & Rehabilitation) Physician
-----------------------------------------------------
License Number | P1533
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------