=====================================================
General NPI Number Information
=====================================================
NPI Number | 1629056304
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SHANNON RAY SCHRADER MD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/04/2006
-----------------------------------------------------
Last Update Date | 12/26/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4101 GREENBRIAR ST #200
-----------------------------------------------------
City | HOUSTON
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77098-5294
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 713-526-7736
-----------------------------------------------------
Fax | 713-524-3155
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2211 NORFOLK ST STE 1050
-----------------------------------------------------
City | HOUSTON
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77098-4044
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 713-526-7736
-----------------------------------------------------
Fax | 713-524-3155
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | H8386
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------