=====================================================
General NPI Number Information
=====================================================
NPI Number | 1467688333
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | KATY SURGICAL ASSISTANTS INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/05/2009
-----------------------------------------------------
Last Update Date | 06/05/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4010 FULFORD CT
-----------------------------------------------------
City | KATY
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77450-5239
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 713-301-9330
-----------------------------------------------------
Fax | 281-398-0451
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4010 FULFORD CT
-----------------------------------------------------
City | KATY
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77450-5239
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 713-301-9330
-----------------------------------------------------
Fax | 281-398-0451
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | SURGICAL ASSISTANT
-----------------------------------------------------
Name | BLAND EDMUND CHAMBERLAIN III
-----------------------------------------------------
Credential | LSA
-----------------------------------------------------
Telephone | 713-301-9330
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363AS0400X
-----------------------------------------------------
Taxonomy Name | Surgical Physician Assistant
-----------------------------------------------------
License Number | SA490938
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------