=====================================================
General NPI Number Information
=====================================================
NPI Number | 1356712095
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | RUSSELL C VANBIBER MD, PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/07/2015
-----------------------------------------------------
Last Update Date | 10/07/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2500 FONDREN RD SUITE NUMBER 255
-----------------------------------------------------
City | HOUSTON
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77063-2308
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 832-769-3313
-----------------------------------------------------
Fax | 832-769-3307
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2500 FONDREN RD SUITE NUMBER 255
-----------------------------------------------------
City | HOUSTON
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77063-2308
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 832-769-3313
-----------------------------------------------------
Fax | 832-769-3307
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PHYSICIAN
-----------------------------------------------------
Name | DR. RUSSELL C VANBIBER III
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 832-769-3313
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261Q00000X
-----------------------------------------------------
Taxonomy Name | Clinic/Center
-----------------------------------------------------
License Number | G5728
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------