MEDICARE: SAN JACINTO MEDICAL GROUP

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

General Provider Information

NPI Number	:	1962456897
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SAN JACINTO MEDICAL GROUP

Provider Business Mailing Address
First Line	:	4301 GARTH RD
Second Line	:	SUITE 400
City	:	BAYTOWN
State	:	TX
Zip	:	77521-3153
Country	:	US
Telephone Number	:	281-420-8502
Fax Number	:	281-420-8480

Provider Business Practice Location Address
First Line	:	2610 N ALEXANDER DR
Second Line	:
City	:	BAYTOWN
State	:	TX
Zip	:	77520-3368
Country	:	US
Telephone Number	:	281-420-6200
Fax Number	:	281-425-2187

Authorized Official
Title or Position	:	CREDENTIALING COORDINATOR
Name	:	JUNE E LOFTIS
Credential	:
Telephone Number	:	281-420-8502

Provider Enumeration Date	:	05/22/2006
Last Update Date	:	02/26/2008

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