Provider Demographics
NPI:1992762991
Name:HARLAN WICHELHAUS, MD, PA
Entity type:Organization
Organization Name:HARLAN WICHELHAUS, MD, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:HARLAN
Authorized Official - Middle Name:P
Authorized Official - Last Name:WICHELHAUS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:409-935-1988
Mailing Address - Street 1:1718 N AMBURN RD
Mailing Address - Street 2:SUITE B
Mailing Address - City:TEXAS CITY
Mailing Address - State:TX
Mailing Address - Zip Code:77591-2490
Mailing Address - Country:US
Mailing Address - Phone:409-935-1988
Mailing Address - Fax:409-933-4898
Practice Address - Street 1:1718 N AMBURN RD
Practice Address - Street 2:SUITE B
Practice Address - City:TEXAS CITY
Practice Address - State:TX
Practice Address - Zip Code:77591-2490
Practice Address - Country:US
Practice Address - Phone:409-935-1988
Practice Address - Fax:409-933-4898
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-26
Last Update Date:2012-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXJ0727174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1720807-01Medicaid
TN0963910-01Medicaid
TX00306YMedicare ID - Type Unspecified