=====================================================
General NPI Number Information
=====================================================
NPI Number | 1144852112
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | STEADFAST PRIMARY CARE, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/07/2020
-----------------------------------------------------
Last Update Date | 01/31/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 24968 KATY RANCH RD UNIT 300
-----------------------------------------------------
City | KATY
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77494-3407
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 346-998-5000
-----------------------------------------------------
Fax | 281-394-2057
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3916 LILY PARK LN
-----------------------------------------------------
City | FULSHEAR
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77441-1875
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 346-307-5707
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRACTICE MANAGER
-----------------------------------------------------
Name | STEVE HARDIE
-----------------------------------------------------
Credential | MBA
-----------------------------------------------------
Telephone | 346-998-5000
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------