Provider Demographics
NPI:1104329440
Name:DEERBROOK CATH LAB LLC
Entity type:Organization
Organization Name:DEERBROOK CATH LAB LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CO-OWNER
Authorized Official - Prefix:
Authorized Official - First Name:RICKY
Authorized Official - Middle Name:PAUL
Authorized Official - Last Name:GANIM
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:281-446-6656
Mailing Address - Street 1:18450 HWY 59 SUITE 101
Mailing Address - Street 2:
Mailing Address - City:HUMBLE
Mailing Address - State:TX
Mailing Address - Zip Code:77338
Mailing Address - Country:US
Mailing Address - Phone:281-446-6656
Mailing Address - Fax:281-446-6657
Practice Address - Street 1:18450 HWY 59 SUITE 101
Practice Address - Street 2:
Practice Address - City:HUMBLE
Practice Address - State:TX
Practice Address - Zip Code:77338
Practice Address - Country:US
Practice Address - Phone:281-446-6656
Practice Address - Fax:281-446-6657
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-03-13
Last Update Date:2020-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional CardiologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX388654101Medicaid
TX663151OtherMEDICARE