Provider Demographics
NPI:1285763268
Name:DOC ON THE BAY ASSOCIATED ENTERPRISES INCORPORATED
Entity type:Organization
Organization Name:DOC ON THE BAY ASSOCIATED ENTERPRISES INCORPORATED
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:LAURIE
Authorized Official - Middle Name:
Authorized Official - Last Name:KILLAM
Authorized Official - Suffix:
Authorized Official - Credentials:OTRL
Authorized Official - Phone:281-452-3547
Mailing Address - Street 1:15055 EAST FWY STE C10
Mailing Address - Street 2:
Mailing Address - City:CHANNELVIEW
Mailing Address - State:TX
Mailing Address - Zip Code:77530-4142
Mailing Address - Country:US
Mailing Address - Phone:281-452-3547
Mailing Address - Fax:
Practice Address - Street 1:15055 EAST FWY STE C10
Practice Address - Street 2:
Practice Address - City:CHANNELVIEW
Practice Address - State:TX
Practice Address - Zip Code:77530-4142
Practice Address - Country:US
Practice Address - Phone:281-452-3547
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-05
Last Update Date:2008-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXH5715207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX11525501Medicaid
TX111525501Medicaid
TX111525504Medicaid
TX193614801Medicaid
TX00630VOtherBLUE CROSS BLUE SHIELD
TX111525504Medicaid