1972541423 NPI number — THIRD COAST EMERGENCY PHYSICIANS SID PETERSON PA

Table of content: (NPI 1972541423)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1972541423 NPI number — THIRD COAST EMERGENCY PHYSICIANS SID PETERSON PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
THIRD COAST EMERGENCY PHYSICIANS SID PETERSON 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:
1972541423
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/27/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
6300 LA CALMA DR
Provider Second Line Business Mailing Address:
SUITE 200
Provider Business Mailing Address City Name:
AUSTIN
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
78752-3843
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
512-452-8533
Provider Business Mailing Address Fax Number:
512-452-9306

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
551 HILL COUNTRY DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
KERRVILLE
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
78028-6085
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
830-896-4200
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
06/04/2006

Additional Information

Authorized Official

Authorized Official Last Name:
ROBERTS
Authorized Official First Name:
SAM
Authorized Official Middle Name:
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
512-452-8533

Provider Taxonomy Codes

  • Taxonomy code: 207P00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 0012NJ . This is a "BCBS" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 0070BD . This is a "BCBS" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 081037603 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 081037604 . This is a "CSHCN" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".




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