MEDICARE: IMPERIAL SURGICAL ASSOCIATES, 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	363AS0400X	Surgical Physician Assistant	PA06288TX	TX

General Provider Information

NPI Number	:	1689955601
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	IMPERIAL SURGICAL ASSOCIATES, LLC

Provider Business Mailing Address
First Line	:	410 DETERING ST
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77007-7127
Country	:	US
Telephone Number	:	903-826-3302
Fax Number	:

Provider Business Practice Location Address
First Line	:	410 DETERING ST
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77007-7127
Country	:	US
Telephone Number	:	903-826-3302
Fax Number	:

Authorized Official
Title or Position	:	MANAGING MEMBER
Name	:	JOSHUA HUNTER GREENE
Credential	:
Telephone Number	:	903-826-3302

Provider Enumeration Date	:	09/03/2011
Last Update Date	:	07/11/2012

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