=====================================================
General NPI Number Information
=====================================================
NPI Number | 1427549831
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | WELLSPRING MEDICAL CARE PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/21/2018
-----------------------------------------------------
Last Update Date | 10/27/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 20171 CHASEWOOD PARK DR
-----------------------------------------------------
City | HOUSTON
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77070-1437
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 612-567-9160
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 14907 HOUSE MARTIN LN
-----------------------------------------------------
City | CYPRESS
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77429-7725
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 612-567-9160
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | HOMAIRA AHMED
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 612-567-9160
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207R00000X
-----------------------------------------------------
Taxonomy Name | Internal Medicine Physician
-----------------------------------------------------
License Number | Q7823
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------