MEDICARE: LEAGUE CITY FAMILY CLINIC, PLLC

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	207Q00000X	Family Medicine Physician	M9365	TX

General Provider Information

NPI Number	:	1700247079
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LEAGUE CITY FAMILY CLINIC, PLLC

Provider Business Mailing Address
First Line	:	1507 WEST LEAGUE CITY PARKWAY
Second Line	:	SUITE 200
City	:	LEAGUE CITY
State	:	TX
Zip	:	77573-6768
Country	:	US
Telephone Number	:	281-525-6290
Fax Number	:	832-905-6173

Provider Business Practice Location Address
First Line	:	1507 WEST LEAGUE CITY PARKWAY
Second Line	:	SUITE 200
City	:	LEAGUE CITY
State	:	TX
Zip	:	77573-6768
Country	:	US
Telephone Number	:	281-525-6290
Fax Number	:	832-905-6173

Authorized Official
Title or Position	:	MEDICAL DIRECTOR
Name	:	DR. HANAN HUSSEIN
Credential	:	MD
Telephone Number	:	281-525-6290

Provider Enumeration Date	:	03/15/2016
Last Update Date	:	04/11/2017

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