MEDICARE: SOUTH MAIN CLINIC, INC

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	208D00000X	General Practice Physician
2	173000000X	Legal Medicine

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	1427078674	OTHER	TX	DR. MONTGOMERY NPI
2	0087MG	OTHER	TX	BCBS

General Provider Information

NPI Number	:	1326068933
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SOUTH MAIN CLINIC, INC

Provider Business Mailing Address
First Line	:	12333 MAIN ST
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77035-6205
Country	:	US
Telephone Number	:	713-729-7600
Fax Number	:	713-729-7603

Provider Business Practice Location Address
First Line	:	12333 MAIN ST
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77035-6205
Country	:	US
Telephone Number	:	713-729-7600
Fax Number	:	713-729-7603

Authorized Official
Title or Position	:	PRESIDENT OWNER
Name	:	MR. ALVARO PINILLA
Credential	:
Telephone Number	:	713-729-7600

Provider Enumeration Date	:	07/20/2006
Last Update Date	:	04/20/2008

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