Provider Demographics
NPI:1164505434
Name:MEMORIAL WELLNESS CENTER PA
Entity type:Organization
Organization Name:MEMORIAL WELLNESS CENTER PA
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:SUSAN
Authorized Official - Middle Name:
Authorized Official - Last Name:VOGEL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:713-932-6333
Mailing Address - Street 1:1201 DAIRY ASHFORD ST
Mailing Address - Street 2:SUITE 118
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77079-3023
Mailing Address - Country:US
Mailing Address - Phone:713-932-6333
Mailing Address - Fax:
Practice Address - Street 1:1201 DAIRY ASHFORD ST
Practice Address - Street 2:SUITE 118
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77079-3023
Practice Address - Country:US
Practice Address - Phone:713-932-6333
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-23
Last Update Date:2014-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX218679301Medicaid
OA5379Medicare PIN