Provider Demographics
NPI:1871617563
Name:ST MICHAELS CENTER FOR SPECIAL SURGERY LTD
Entity type:Organization
Organization Name:ST MICHAELS CENTER FOR SPECIAL SURGERY LTD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:RANDOLPH
Authorized Official - Middle Name:ALPHONSE
Authorized Official - Last Name:LOPEZ
Authorized Official - Suffix:
Authorized Official - Credentials:MD,
Authorized Official - Phone:713-812-1612
Mailing Address - Street 1:PO BOX 924369
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77292-4369
Mailing Address - Country:US
Mailing Address - Phone:713-812-1612
Mailing Address - Fax:
Practice Address - Street 1:3726 DACOMA ST
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77092-8906
Practice Address - Country:US
Practice Address - Phone:713-812-1612
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-19
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX008261261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX=========OtherTAX ID