MEDICARE: SOUTHEAST TEXAS HEART AND LUNG SURGEONS, LLP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	208G00000X	Thoracic Surgery (Cardiothoracic Vascular Surgery) Physician	F4287	TX

General Provider Information

NPI Number	:	1053347393
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SOUTHEAST TEXAS HEART AND LUNG SURGEONS, LLP

Provider Business Mailing Address
First Line	:	2501 JIMMY JOHNSON BLVD.
Second Line	:	SUITE 201
City	:	PORT ARTHUR
State	:	TX
Zip	:	77640-2900
Country	:	US
Telephone Number	:	409-722-4001
Fax Number	:	409-722-4013

Provider Business Practice Location Address
First Line	:	2501 JIMMY JOHNSON BLVD.
Second Line	:	SUITE 201
City	:	PORT ARTHUR
State	:	TX
Zip	:	77640-2900
Country	:	US
Telephone Number	:	409-722-4001
Fax Number	:	409-722-4013

Authorized Official
Title or Position	:	PARTNER-PHYSICIAN
Name	:	DR. OTTO LAWAYNE MILLER JR.
Credential	:	M.D.
Telephone Number	:	409-722-4001

Provider Enumeration Date	:	06/25/2006
Last Update Date	:	08/22/2020

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