1104009513 NPI number — MID VALLEY ADULT SPECIALISTS PA

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1104009513 NPI number — MID VALLEY ADULT SPECIALISTS PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MID VALLEY ADULT SPECIALISTS PA
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1104009513
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/14/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1010 JAMES ST STE B
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WESLACO
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
78596-6654
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
956-968-1621
Provider Business Mailing Address Fax Number:
956-447-8626

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1010 JAMES ST STE B
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WESLACO
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
78596-6654
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
956-968-1621
Provider Business Practice Location Address Fax Number:
956-447-8626
Provider Enumeration Date:
12/07/2007

Additional Information

Authorized Official

Authorized Official Last Name:
MCDOUGAL
Authorized Official First Name:
PEDRO
Authorized Official Middle Name:
E
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
956-968-1621

Provider Taxonomy Codes

  • Taxonomy code: 207R00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 092279101 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".




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