Provider Demographics
NPI:1902494743
Name:TEXAS MODERN GASTROENTEROLOGY
Entity type:Organization
Organization Name:TEXAS MODERN GASTROENTEROLOGY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN OWNER/PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:VIVIAN
Authorized Official - Middle Name:SAMI
Authorized Official - Last Name:EBRAHIM
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:214-729-0111
Mailing Address - Street 1:1216 CHURCH ST
Mailing Address - Street 2:
Mailing Address - City:SULPHUR SPRINGS
Mailing Address - State:TX
Mailing Address - Zip Code:75482-2108
Mailing Address - Country:US
Mailing Address - Phone:903-588-2222
Mailing Address - Fax:903-588-2225
Practice Address - Street 1:1216 CHURCH ST
Practice Address - Street 2:
Practice Address - City:SULPHUR SPRINGS
Practice Address - State:TX
Practice Address - Zip Code:75482-2108
Practice Address - Country:US
Practice Address - Phone:903-588-2222
Practice Address - Fax:903-588-2225
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-01-07
Last Update Date:2024-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterologyGroup - Single Specialty