MEDICARE: TEXAS MANAGERIAL MEDICAL SERVICES, 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	2085R0202X	Diagnostic Radiology Physician
2	207Q00000X	Family Medicine Physician

General Provider Information

NPI Number	:	1144653171
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	TEXAS MANAGERIAL MEDICAL SERVICES, LLC

Provider Business Mailing Address
First Line	:	20320 NORTHWEST FWY
Second Line	:	SUITE 900
City	:	JERSEY VILLAGE
State	:	TX
Zip	:	77065-5641
Country	:	US
Telephone Number	:	281-586-3888
Fax Number	:	281-440-2020

Provider Business Practice Location Address
First Line	:	20320 NORTHWEST FWY
Second Line	:	SUITE 900
City	:	JERSEY VILLAGE
State	:	TX
Zip	:	77065-5641
Country	:	US
Telephone Number	:	281-586-3888
Fax Number	:	281-440-2020

Authorized Official
Title or Position	:	CREDENTIALING DEPARTMENT
Name	:	ANA BORJA
Credential	:
Telephone Number	:	281-453-7224

Provider Enumeration Date	:	08/13/2013
Last Update Date	:	08/13/2013

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