MEDICARE: NORTHEAST HOUSTON ONE MEDICAL GROUP, PLLC

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	261QP2300X	Primary Care Clinic/Center

General Provider Information

NPI Number	:	1144987876
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	NORTHEAST HOUSTON ONE MEDICAL GROUP, PLLC

Provider Business Mailing Address
First Line	:	16131 N ELDRIDGE PKWY STE 100
Second Line	:
City	:	TOMBALL
State	:	TX
Zip	:	77377-9130
Country	:	US
Telephone Number	:	281-429-8526
Fax Number	:

Provider Business Practice Location Address
First Line	:	18321 W LAKE HOUSTON PKWY STE 420
Second Line	:
City	:	HUMBLE
State	:	TX
Zip	:	77346-3587
Country	:	US
Telephone Number	:	281-531-2000
Fax Number	:

Authorized Official
Title or Position	:	MANAGER
Name	:	WELTON WILSON
Credential	:
Telephone Number	:	281-429-8526

Provider Enumeration Date	:	11/17/2021
Last Update Date	:	11/17/2021

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