1255318630 NPI number — EDWARD C. JUAREZ, MD, PA

Table of content: (NPI 1609532316)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1255318630 NPI number — EDWARD C. JUAREZ, MD, PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
EDWARD C. JUAREZ, MD, 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:
EASTSIDE MEDICAL CARE CENTER, PA
Provider Other Organization Name Type Code:
3
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:
1255318630
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/19/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 12520
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
EL PASO
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
79913-0520
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
915-842-0504
Provider Business Mailing Address Fax Number:
915-842-0448

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1721 N LEE TREVINO DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
EL PASO
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
79936-4521
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
915-590-9424
Provider Business Practice Location Address Fax Number:
915-590-9049
Provider Enumeration Date:
12/28/2005

Additional Information

Authorized Official

Authorized Official Last Name:
JUAREZ
Authorized Official First Name:
LAURENCE
Authorized Official Middle Name:
Authorized Official Title or Position:
ADMINISTRATOR
Authorized Official Telephone Number:
915-842-0504

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207R00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 208D00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: L0399 , issued by the state of ( NM ) . This identifiers is of the category "MEDICAID".
  • Identifier: CD3874 . This is a "PALMETTO GBA" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 0858375-01 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".




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