MEDICARE: HAZTECH MSO, 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	2080P0202X	Pediatric Cardiology Physician
2	291U00000X	Clinical Medical Laboratory

General Provider Information

NPI Number	:	1386305068
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	HAZTECH MSO, LLC

Provider Business Mailing Address
First Line	:	18648 MCKAY DR STE 120
Second Line	:
City	:	HUMBLE
State	:	TX
Zip	:	77338-5724
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	580 S DENTON TAP RD STE 280
Second Line	:
City	:	COPPELL
State	:	TX
Zip	:	75019-4073
Country	:	US
Telephone Number	:	713-737-5912
Fax Number	:

Authorized Official
Title or Position	:	MANAGER
Name	:	PAUL TATE
Credential	:
Telephone Number	:	713-737-5912

Provider Enumeration Date	:	01/05/2022
Last Update Date	:	05/04/2022

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Directions to “HAZTECH MSO, LLC ” Practice Location

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