=====================================================
General NPI Number Information
=====================================================
NPI Number | 1689202004
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BAYOU SURGICAL ASSISTANTS INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/31/2020
-----------------------------------------------------
Last Update Date | 07/01/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 121 N POST OAK LN APT 2204
-----------------------------------------------------
City | HOUSTON
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77024-7717
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 832-807-8717
-----------------------------------------------------
Fax | 713-804-8717
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 36212
-----------------------------------------------------
City | HOUSTON
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77236-6212
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 832-804-8717
-----------------------------------------------------
Fax | 832-804-8717
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CHIEF EXECUTIVE OFFICER
-----------------------------------------------------
Name | THOMAS KIRK
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 832-804-8703
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 174400000X
-----------------------------------------------------
Taxonomy Name | Specialist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------