Provider Demographics
NPI:1477604775
Name:FORT BEND INTERNAL MEDICINE AND PEDIATRICS, P.A.
Entity type:Organization
Organization Name:FORT BEND INTERNAL MEDICINE AND PEDIATRICS, P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:HARI
Authorized Official - Middle Name:KRISHNA
Authorized Official - Last Name:SUSARLA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:281-208-1908
Mailing Address - Street 1:PO BOX 17295
Mailing Address - Street 2:
Mailing Address - City:SUGAR LAND
Mailing Address - State:TX
Mailing Address - Zip Code:77496-7295
Mailing Address - Country:US
Mailing Address - Phone:281-208-1908
Mailing Address - Fax:281-208-1930
Practice Address - Street 1:4646 RIVERSTONE BLVD
Practice Address - Street 2:
Practice Address - City:MISSOURI CITY
Practice Address - State:TX
Practice Address - Zip Code:77459-6141
Practice Address - Country:US
Practice Address - Phone:281-208-1908
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-15
Last Update Date:2008-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXL7205208000000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
No208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX0094PDOtherBC BS PROVIDER NUMBER
TX00X518Medicare ID - Type UnspecifiedFORT BEND CTY GROUP PTAN#
TX00X519Medicare ID - Type UnspecifiedHARRIS COUNTY PTAN #
TX00X518Medicare PIN