1558503839 NPI number — SUSAN PORTNOY EPNER, M.D., P.A.

Table of content: (NPI 1558503839)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1558503839 NPI number — SUSAN PORTNOY EPNER, M.D., P.A.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SUSAN PORTNOY EPNER, M.D., P.A.
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:
1558503839
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/07/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4903 GOLDEN QUAIL
Provider Second Line Business Mailing Address:
SUITE 104
Provider Business Mailing Address City Name:
SAN ANTONIO
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
78240-1584
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
210-877-2727
Provider Business Mailing Address Fax Number:
210-877-0267

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4903 GOLDEN QUAIL
Provider Second Line Business Practice Location Address:
SUITE 104
Provider Business Practice Location Address City Name:
SAN ANTONIO
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
78240-1584
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
210-877-2727
Provider Business Practice Location Address Fax Number:
210-877-0267
Provider Enumeration Date:
04/01/2009

Additional Information

Authorized Official

Authorized Official Last Name:
EPNER
Authorized Official First Name:
SUSAN
Authorized Official Middle Name:
PORTNOY
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
210-497-0494

Provider Taxonomy Codes

  • Taxonomy code: 2084N0400X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 104240003 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 0066TE . This is a "BCBS GROUP" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 8CG786 . This is a "BCBS INDIVIDUAL" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".




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