Provider Demographics
NPI:1194859629
Name:ENTRAMED, INC
Entity type:Organization
Organization Name:ENTRAMED, INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CO-CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:JEREMY
Authorized Official - Middle Name:W
Authorized Official - Last Name:CRABB
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:817-600-6233
Mailing Address - Street 1:27905 COMMERCIAL PARK RD STE 240
Mailing Address - Street 2:
Mailing Address - City:TOMBALL
Mailing Address - State:TX
Mailing Address - Zip Code:77375-6580
Mailing Address - Country:US
Mailing Address - Phone:713-955-2123
Mailing Address - Fax:281-742-2589
Practice Address - Street 1:27905 COMMERCIAL PARK RD STE 240
Practice Address - Street 2:
Practice Address - City:TOMBALL
Practice Address - State:TX
Practice Address - Zip Code:77375-6580
Practice Address - Country:US
Practice Address - Phone:713-955-2123
Practice Address - Fax:281-742-2589
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-15
Last Update Date:2025-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
133V00000X, 174N00000X
TX0051466332B00000X, 332BP3500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes332BP3500XSuppliersDurable Medical Equipment & Medical SuppliesParenteral & Enteral Nutrition
No133V00000XDietary & Nutritional Service ProvidersDietitian, RegisteredGroup - Multi-Specialty
No174N00000XOther Service ProvidersLactation Consultant, Non-RNGroup - Multi-Specialty
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT1194859629Medicaid
CO1194859629Medicaid
AK1653815Medicaid
NE10026750400Medicaid
NM28430310Medicaid
TX145697201Medicaid
TX145698001Medicaid
WA2106483Medicaid