=====================================================
General NPI Number Information
=====================================================
NPI Number | 1689955601
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | IMPERIAL SURGICAL ASSOCIATES, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/03/2011
-----------------------------------------------------
Last Update Date | 07/11/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 410 DETERING ST
-----------------------------------------------------
City | HOUSTON
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77007-7127
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 903-826-3302
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 410 DETERING ST
-----------------------------------------------------
City | HOUSTON
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77007-7127
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 903-826-3302
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MANAGING MEMBER
-----------------------------------------------------
Name | JOSHUA HUNTER GREENE
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 903-826-3302
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363AS0400X
-----------------------------------------------------
Taxonomy Name | Surgical Physician Assistant
-----------------------------------------------------
License Number | PA06288TX
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------