=====================================================
General NPI Number Information
=====================================================
NPI Number | 1801510110
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PRIME MEDICAL GROUP LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/29/2022
-----------------------------------------------------
Last Update Date | 09/29/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 13480 VETERANS MEMORIAL DR STE R1
-----------------------------------------------------
City | HOUSTON
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77014-1670
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 281-587-1600
-----------------------------------------------------
Fax | 281-587-1601
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 13480 VETERANS MEMORIAL DR STE R1
-----------------------------------------------------
City | HOUSTON
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77014-1670
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 281-587-1600
-----------------------------------------------------
Fax | 281-587-1601
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | BILLING DIRECTOR
-----------------------------------------------------
Name | RAQUEL WILLIAMS-WHEELER
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 713-409-4430
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QM1300X
-----------------------------------------------------
Taxonomy Name | Multi-Specialty Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------