=====================================================
General NPI Number Information
=====================================================
NPI Number | 1861625303
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | TRIAD SURGERY CENTER, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/01/2009
-----------------------------------------------------
Last Update Date | 09/01/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 16151 CAIRNWAY DR
-----------------------------------------------------
City | HOUSTON
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77084-3550
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 281-463-6309
-----------------------------------------------------
Fax | 281-463-6835
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 840967
-----------------------------------------------------
City | HOUSTON
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77284-0967
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 713-796-2200
-----------------------------------------------------
Fax | 713-796-2232
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | PAUL I COOK
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 713-796-2200
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363AS0400X
-----------------------------------------------------
Taxonomy Name | Surgical Physician Assistant
-----------------------------------------------------
License Number | SA00288
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------