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General NPI Number Information
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NPI Number | 1457574006
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Entity Type | Organization
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Legal Business Name | GREATER GULF HEALTH PLAN, LLC
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Dates
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Enumeration Date | 04/11/2007
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Last Update Date | 06/18/2008
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Provider Practice Location Address
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Address Line | 260 N SAM HOUSTON PKWY E STE 220
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City | HOUSTON
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State | TX
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Zip | 77060-2022
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Country | US
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Telephone | 281-447-6800
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Fax | 281-447-6802
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Provider Business Mailing Address
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Address Line | 260 N SAM HOUSTON PKWY E SUITE 220
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City | HOUSTON
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State | TX
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Zip | 77060-2018
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Country | US
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Telephone | 281-447-6800
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Fax | 281-447-6802
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Authorized Official
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Title or Position | PRESIDENT
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Name | MR. LAWRENCE J WEDEKIND
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Credential |
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Telephone | 281-447-6800
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 208D00000X
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Taxonomy Name | General Practice Physician
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License Number | 01486663
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License Number State | TX
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