Provider Demographics
NPI:1104064500
Name:MEMORIAL ENT SURGICAL AFFILIATES, P.A.
Entity type:Organization
Organization Name:MEMORIAL ENT SURGICAL AFFILIATES, P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:SOURABH
Authorized Official - Middle Name:
Authorized Official - Last Name:SANDUJA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:713-960-6692
Mailing Address - Street 1:PO BOX 722077
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77272-2077
Mailing Address - Country:US
Mailing Address - Phone:713-960-6692
Mailing Address - Fax:713-960-6691
Practice Address - Street 1:9901 TOWN PARK DR
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77036-2343
Practice Address - Country:US
Practice Address - Phone:713-960-6692
Practice Address - Fax:713-960-6691
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-01-23
Last Update Date:2009-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical