MEDICARE: MID TOWN OB GYN ASSOCIATES, 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	302R00000X	Health Maintenance Organization	C17040	TX

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	129169203	OTHER	TX	TEXAS HEALTH NETWORK
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1487776670
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MID TOWN OB GYN ASSOCIATES, INC

Provider Business Mailing Address
First Line	:	4315 LOCKWOOD DR
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77026-4117
Country	:	US
Telephone Number	:	713-675-1749
Fax Number	:	713-670-8190

Provider Business Practice Location Address
First Line	:	4315 LOCKWOOD DR
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77026-4117
Country	:	US
Telephone Number	:	713-675-1749
Fax Number	:	713-670-8190

Authorized Official
Title or Position	:	PRESIDENT
Name	:	MR. BLANCHARD TUCKER HOLLINS
Credential	:
Telephone Number	:	713-675-1749

Provider Enumeration Date	:	04/06/2007
Last Update Date	:	08/11/2009

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