MEDICARE: GREATER TEXAS SPORTS MEDICINE 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	225100000X	Physical Therapist

General Provider Information

NPI Number	:	1093489049
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GREATER TEXAS SPORTS MEDICINE LLC

Provider Business Mailing Address
First Line	:	2600 S LOOP W STE 648
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77054-5601
Country	:	US
Telephone Number	:	678-687-7494
Fax Number	:	281-664-3769

Provider Business Practice Location Address
First Line	:	2600 S LOOP W STE 648
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77054-5601
Country	:	US
Telephone Number	:	678-687-7494
Fax Number	:	832-915-5523

Authorized Official
Title or Position	:	DIRECTOR
Name	:	MAULIK PANCHOLI
Credential	:	PT, DPT
Telephone Number	:	678-687-8393

Provider Enumeration Date	:	08/03/2021
Last Update Date	:	12/05/2024

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