MEDICARE: BAHAR IMMUNIZATION CENTER LLC

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	207Q00000X	Family Medicine Physician
2	2080A0000X	Pediatric Adolescent Medicine Physician

General Provider Information

NPI Number	:	1053725978
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BAHAR IMMUNIZATION CENTER LLC

Provider Business Mailing Address
First Line	:	5200 MITCHEDALLE SUITE F-27
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77092
Country	:	US
Telephone Number	:	832-878-2044
Fax Number	:

Provider Business Practice Location Address
First Line	:	5200 MITCHELLDALE ST
Second Line	:	F-27
City	:	HOUSTON
State	:	TX
Zip	:	77092-7206
Country	:	US
Telephone Number	:	832-878-2044
Fax Number	:

Authorized Official
Title or Position	:	MEMBER MANAGER
Name	:	SIAVASH TEHRANI
Credential	:
Telephone Number	:	832-878-2044

Provider Enumeration Date	:	06/18/2014
Last Update Date	:	07/15/2015

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