MEDICARE: MAEGEN BREANN BUNCH PTA

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	208100000X	Physical Medicine & Rehabilitation Physician	2150272	TX

General Provider Information

NPI Number	:	1699404616
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MAEGEN BREANN BUNCH PTA

Provider Business Mailing Address
First Line	:	11120 NORTH FWY
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77037-1029
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	11120 NORTH FWY
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77037-1029
Country	:	US
Telephone Number	:	281-875-1800
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/06/2022
Last Update Date	:	06/06/2022

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