MEDICARE: INSURANCE SERVICES GREEN, CO.

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	261QH0100X	Health Service Clinic/Center	04322567	TX

General Provider Information

NPI Number	:	1316188444
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	INSURANCE SERVICES GREEN, CO.

Provider Business Mailing Address
First Line	:	1200 SMITH ST
Second Line	:	STE 1600
City	:	HOUSTON
State	:	TX
Zip	:	77002-4313
Country	:	US
Telephone Number	:	713-353-4634
Fax Number	:

Provider Business Practice Location Address
First Line	:	1200 SMITH ST
Second Line	:	STE 1600
City	:	HOUSTON
State	:	TX
Zip	:	77002-4313
Country	:	US
Telephone Number	:	713-353-4634
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	MR. JAMES M FORTENBERRY
Credential	:
Telephone Number	:	713-353-4634

Provider Enumeration Date	:	03/19/2009
Last Update Date	:	03/19/2009

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