Provider Demographics
NPI:1720263221
Name:SURGICAL SPECIALISTS OF CLEAR LAKE PLLC
Entity type:Organization
Organization Name:SURGICAL SPECIALISTS OF CLEAR LAKE PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:TODD
Authorized Official - Middle Name:
Authorized Official - Last Name:EVANS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:281-332-4596
Mailing Address - Street 1:200 MEDICAL CENTER BLVD
Mailing Address - Street 2:STE 101
Mailing Address - City:WEBSTER
Mailing Address - State:TX
Mailing Address - Zip Code:77598-4226
Mailing Address - Country:US
Mailing Address - Phone:281-332-4596
Mailing Address - Fax:
Practice Address - Street 1:200 MEDICAL CENTER BLVD
Practice Address - Street 2:STE 101
Practice Address - City:WEBSTER
Practice Address - State:TX
Practice Address - Zip Code:77598-4226
Practice Address - Country:US
Practice Address - Phone:281-332-4596
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-02
Last Update Date:2008-11-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX193267501Medicaid
TXDH1753OtherRAILROAD MEDICARE
TX00Y857Medicare PIN