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General NPI Number Information
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NPI Number | 1770677130
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Entity Type | Organization
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Legal Business Name | MEDICAL INFECTIOUS DISEASE CONSULTING SERVICE
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Dates
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Enumeration Date | 10/02/2006
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 18951 N MEMORIAL
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City | HUMBLE
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State | TX
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Zip | 77338-4217
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Country | US
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Telephone | 281-540-7700
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 131224
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City | THE WOODLANDS
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State | TX
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Zip | 77393
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Country | US
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Telephone | 281-893-4376
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Fax | 281-419-6362
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Authorized Official
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Title or Position | PRESIDENT
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Name | RICARDO BOLIVAR
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Credential | MD
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Telephone | 281-893-4376
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207RI0200X
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Taxonomy Name | Infectious Disease Physician
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License Number | E7377
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License Number State | TX
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