=====================================================
General NPI Number Information
=====================================================
NPI Number | 1912365628
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | RICHMOND GI PATHOLOGY PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/09/2016
-----------------------------------------------------
Last Update Date | 02/09/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1601 MAIN ST SUITE 401 B
-----------------------------------------------------
City | RICHMOND
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77469-3247
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 281-741-3809
-----------------------------------------------------
Fax | 888-848-2032
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 841992
-----------------------------------------------------
City | PEARLAND
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77584-0028
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 281-741-3809
-----------------------------------------------------
Fax | 888-848-2032
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | ADMINISTRATOR
-----------------------------------------------------
Name | NIZAR CHARAFEDDINE
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 281-741-3809
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 291U00000X
-----------------------------------------------------
Taxonomy Name | Clinical Medical Laboratory
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------