Provider Demographics
NPI:1588779276
Name:FOURTH WARD CLINIC
Entity type:Organization
Organization Name:FOURTH WARD CLINIC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CHIEF OPERATING OFFICER
Authorized Official - Prefix:MRS
Authorized Official - First Name:TUESDAY
Authorized Official - Middle Name:
Authorized Official - Last Name:COFFMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:713-529-3597
Mailing Address - Street 1:190 HEIGHTS BLVD
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77007-3729
Mailing Address - Country:US
Mailing Address - Phone:713-529-3597
Mailing Address - Fax:713-529-9169
Practice Address - Street 1:190 HEIGHTS BLVD
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77007-3729
Practice Address - Country:US
Practice Address - Phone:713-529-3597
Practice Address - Fax:713-529-9169
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-20
Last Update Date:2015-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX126821105Medicaid
TX671829Medicare ID - Type Unspecified