Provider Demographics
NPI:1194723296
Name:GULF COAST CANCER & DIAGNOSTIC CENTER AT SOUTHEAST
Entity type:Organization
Organization Name:GULF COAST CANCER & DIAGNOSTIC CENTER AT SOUTHEAST
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:A
Authorized Official - Last Name:DANDREA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:713-474-1414
Mailing Address - Street 1:PO BOX 7894
Mailing Address - Street 2:
Mailing Address - City:PASADENA
Mailing Address - State:TX
Mailing Address - Zip Code:77508-7894
Mailing Address - Country:US
Mailing Address - Phone:713-474-1414
Mailing Address - Fax:713-474-8477
Practice Address - Street 1:12811 BEAMER RD
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77089-6140
Practice Address - Country:US
Practice Address - Phone:713-474-1414
Practice Address - Fax:713-474-8477
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-07-12
Last Update Date:2016-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QX0203XAmbulatory Health Care FacilitiesClinic/CenterOncology, Radiation
No261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX149577201Medicaid
TX0212DCOtherBLUE CROSS
TX0212DCOtherBLUE CROSS