MEDICARE: LEE R COLOSIMO MD 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	208G00000X	Thoracic Surgery (Cardiothoracic Vascular Surgery) Physician	G1636	TX

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	8511K0	OTHER	TX	BLUE CROSS OF TEXAS

General Provider Information

NPI Number	:	1780868265
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LEE R COLOSIMO MD PA

Provider Business Mailing Address
First Line	:	19411 MCKAY BLVD
Second Line	:	SUITE 250
City	:	HUMBLE
State	:	TX
Zip	:	77338-5713
Country	:	US
Telephone Number	:	281-540-3838
Fax Number	:	281-540-6773

Provider Business Practice Location Address
First Line	:	19411 MCKAY BLVD
Second Line	:	SUITE 250
City	:	HUMBLE
State	:	TX
Zip	:	77338-5713
Country	:	US
Telephone Number	:	281-540-3838
Fax Number	:	281-540-6773

Authorized Official
Title or Position	:	PHYSICIAN OWNER
Name	:	DR. LEE RALPH COLOSIMO
Credential	:	M.D.
Telephone Number	:	281-540-3838

Provider Enumeration Date	:	12/20/2007
Last Update Date	:	12/20/2007

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