MEDICARE: HOUSTON BRAIN AND SPINE, 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	207T00000X	Neurological Surgery Physician	M2187	TX

General Provider Information

NPI Number	:	1306184064
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	HOUSTON BRAIN AND SPINE, LLC

Provider Business Mailing Address
First Line	:	2616 MASON ST
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77006-3116
Country	:	US
Telephone Number	:	281-333-1300
Fax Number	:	281-333-1303

Provider Business Practice Location Address
First Line	:	2616 MASON ST
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77006-3116
Country	:	US
Telephone Number	:	281-333-1300
Fax Number	:	281-333-1303

Authorized Official
Title or Position	:	OWNER
Name	:	JEREMY C WANG
Credential	:	M.D.
Telephone Number	:	281-333-1300

Provider Enumeration Date	:	01/30/2013
Last Update Date	:	01/30/2013

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