=====================================================
General NPI Number Information
=====================================================
NPI Number | 1598196206
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | EBD BEMC BURLESON, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/05/2013
-----------------------------------------------------
Last Update Date | 05/10/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1776 HIGHWAY 287 N STE 100
-----------------------------------------------------
City | MANSFIELD
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 76063-7628
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 8686 NEW TRAILS DR SUITE 100
-----------------------------------------------------
City | THE WOODLANDS
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77381-1176
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 713-637-1144
-----------------------------------------------------
Fax | 281-292-3585
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PROVIDER ENROLLMENT COORDINATOR
-----------------------------------------------------
Name | MRS. TINA JOHNSON
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 713-929-2076
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QA1903X
-----------------------------------------------------
Taxonomy Name | Ambulatory Surgical Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 282N00000X
-----------------------------------------------------
Taxonomy Name | General Acute Care Hospital
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------