MEDICARE: EAST TEXAS EYE CENTER PA

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	152W00000X	Optometrist	02830TG	TX
2	207W00000X	Ophthalmology Physician	L2649	TX

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
3	DE8958	OTHER	TX	MEDICARE RAILROAD
5	180044544	OTHER		MEDICARE RAILROAD

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	918304	OTHER		BLOCK VISION
2	21210202328	OTHER		BEECH STREET
4	0084GS	OTHER	TX	BLUE CROSS BLUE SHIELD
6	7114117	OTHER		AETNA
7	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
8	975250	OTHER		ONE HEALTH PLAN
9	4119904	OTHER		CIGNA
10	5248990	OTHER		FIRST HEALTH
11	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
12	21210202328	OTHER		BEECHSTREET
13	5248990	OTHER		CCN

General Provider Information

NPI Number	:	1457385551
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	EAST TEXAS EYE CENTER PA

Provider Business Mailing Address
First Line	:	18700 W LAKE HOUSTON PKWY
Second Line	:	STE B101
City	:	HUMBLE
State	:	TX
Zip	:	77346-3349
Country	:	US
Telephone Number	:	281-812-4000
Fax Number	:	281-812-3331

Provider Business Practice Location Address
First Line	:	901 E HOUSTON ST
Second Line	:	STE B
City	:	CLEVELAND
State	:	TX
Zip	:	77327-4602
Country	:	US
Telephone Number	:	281-659-2020
Fax Number	:	281-659-2030

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. K RAY SHRUM
Credential	:	MD
Telephone Number	:	281-659-2020

Provider Enumeration Date	:	07/11/2006
Last Update Date	:	05/05/2015

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Directions to “EAST TEXAS EYE CENTER PA ” Practice Location

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