=====================================================
General NPI Number Information
=====================================================
NPI Number | 1710452479
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MEDICAL TELEPRESENCE PA
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/09/2018
-----------------------------------------------------
Last Update Date | 11/14/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5302 BELLAIRE BLVD
-----------------------------------------------------
City | BELLAIRE
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77401-3904
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 281-786-0924
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5302 BELLAIRE BLVD
-----------------------------------------------------
City | BELLAIRE
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77401-3904
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | AUTHORIZED OFFICIAL
-----------------------------------------------------
Name | MARIO QUINTANILLA
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 713-826-4600
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207P00000X
-----------------------------------------------------
Taxonomy Name | Emergency Medicine Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 261QE0002X
-----------------------------------------------------
Taxonomy Name | Emergency Care Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 261QU0200X
-----------------------------------------------------
Taxonomy Name | Urgent Care Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------