=====================================================
General NPI Number Information
=====================================================
NPI Number | 1184037525
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | RELIANT PARK PSYCHIATRY
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/03/2014
-----------------------------------------------------
Last Update Date | 06/04/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 7601 FANNIN ST
-----------------------------------------------------
City | HOUSTON
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77054-1905
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 713-795-8874
-----------------------------------------------------
Fax | 713-795-5529
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 7601 FANNIN ST
-----------------------------------------------------
City | HOUSTON
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77054-1905
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 713-795-8874
-----------------------------------------------------
Fax | 713-795-5529
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | M.D
-----------------------------------------------------
Name | IZZELDEEN BABIKER ELHAGE
-----------------------------------------------------
Credential | M.D
-----------------------------------------------------
Telephone | 267-307-7251
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103TP0016X
-----------------------------------------------------
Taxonomy Name | Prescribing (Medical) Psychologist
-----------------------------------------------------
License Number | N8002
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------