=====================================================
General NPI Number Information
=====================================================
NPI Number | 1629601166
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | FAMILY PHYSICIANS AT TOWN & COUNTRY, PLLP
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/12/2020
-----------------------------------------------------
Last Update Date | 02/12/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 10497 TOWN AND COUNTRY WAY STE 360
-----------------------------------------------------
City | HOUSTON
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77024-1143
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 713-341-2100
-----------------------------------------------------
Fax | 713-932-7072
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 10497 TOWN AND COUNTRY WAY STE 360
-----------------------------------------------------
City | HOUSTON
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77024-1143
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 713-341-2100
-----------------------------------------------------
Fax | 713-932-7072
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CREDENTIALING REPRESENTATIVE
-----------------------------------------------------
Name | BRENDA MORENO
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 713-341-2100
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------