=====================================================
General NPI Number Information
=====================================================
NPI Number | 1487945879
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MENNEN T. GALLAS, MD PA
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/20/2011
-----------------------------------------------------
Last Update Date | 04/20/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 21300 PROVINCIAL BLVD
-----------------------------------------------------
City | KATY
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77450-7580
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 281-646-1114
-----------------------------------------------------
Fax | 281-646-1138
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 21300 PROVINCIAL BLVD
-----------------------------------------------------
City | KATY
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77450-7580
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 281-646-1114
-----------------------------------------------------
Fax | 281-646-1138
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. MENNEN THEODORE GALLAS
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 281-646-1114
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208200000X
-----------------------------------------------------
Taxonomy Name | Plastic Surgery Physician
-----------------------------------------------------
License Number | K5105
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------