MEDICARE: BREAST RECONSTRUCTION CENTERS OF HOUSTON

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	208600000X	Surgery Physician	M8534	TX
2	2086S0122X	Plastic and Reconstructive Surgery Physician	M8534	TX

General Provider Information

NPI Number	:	1861941338
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BREAST RECONSTRUCTION CENTERS OF HOUSTON

Provider Business Mailing Address
First Line	:	920 FROSTWOOD DR STE 690
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77024-2468
Country	:	US
Telephone Number	:	832-742-8187
Fax Number	:	855-926-3963

Provider Business Practice Location Address
First Line	:	920 FROSTWOOD DR STE 690
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77024-2468
Country	:	US
Telephone Number	:	832-742-8187
Fax Number	:	855-926-3963

Authorized Official
Title or Position	:	PRESIDENT
Name	:	RAFI BIDROS
Credential	:	MD
Telephone Number	:	832-742-8187

Provider Enumeration Date	:	09/26/2016
Last Update Date	:	09/26/2016

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