=====================================================
General NPI Number Information
=====================================================
NPI Number | 1366647448
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SURGICAL ASSISTANTS OF GREATER HOUSTON
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/18/2007
-----------------------------------------------------
Last Update Date | 11/28/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 8104 EPHRAIM RD
-----------------------------------------------------
City | AUSTIN
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78717-5334
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 512-697-9816
-----------------------------------------------------
Fax | 512-828-6486
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 8104 EPHRAIM RD
-----------------------------------------------------
City | AUSTIN
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78717-5334
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 512-697-9816
-----------------------------------------------------
Fax | 512-828-6486
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO
-----------------------------------------------------
Name | MR. DENNIS MARRERO
-----------------------------------------------------
Credential | O.P.A.-C., CSFA-OS
-----------------------------------------------------
Telephone | 512-697-9816
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 246ZC0007X
-----------------------------------------------------
Taxonomy Name | Surgical Assistant
-----------------------------------------------------
License Number | 103402
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 363AS0400X
-----------------------------------------------------
Taxonomy Name | Surgical Physician Assistant
-----------------------------------------------------
License Number | 604
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------