Provider Demographics
NPI:1679270623
Name:HAVANA MEDICAL GROUP CORP
Entity type:Organization
Organization Name:HAVANA MEDICAL GROUP CORP
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:NORBE
Authorized Official - Middle Name:LUIS
Authorized Official - Last Name:BASULTO BARCELAY
Authorized Official - Suffix:
Authorized Official - Credentials:NP
Authorized Official - Phone:786-556-8819
Mailing Address - Street 1:715 TELEPHONE RD
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77023-3117
Mailing Address - Country:US
Mailing Address - Phone:832-871-4777
Mailing Address - Fax:832-871-4776
Practice Address - Street 1:715 TELEPHONE RD
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77023-3117
Practice Address - Country:US
Practice Address - Phone:832-871-4777
Practice Address - Fax:832-871-4776
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-02-09
Last Update Date:2023-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty
No261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1861628505OtherMOLINA
TX1861628505Medicaid
1861628505OtherAETNA
TX1861628505OtherCOMMUNITY HEALTH CHOICE
TX1861628505OtherBLUE CROSS BLUE SHIELD
TX1861628505OtherUNITED HEALTH CARE