1093371163 NPI number — SAN ANTONIO VASCULAR SPECIALISTS CORP

Table of content: MRS. LISA ANNE MARCINKO PAC (NPI 1942521471)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1093371163 NPI number — SAN ANTONIO VASCULAR SPECIALISTS CORP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SAN ANTONIO VASCULAR SPECIALISTS CORP
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:
6
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:
1093371163
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/05/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
26500 AGOURA RD STE 102-587
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CALABASAS
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
91302-1952
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
818-880-8605
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
9819 HUEBNER RD BLDG 4
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SAN ANTONIO
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
78240-3253
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
210-761-8775
Provider Business Practice Location Address Fax Number:
210-519-0216
Provider Enumeration Date:
05/14/2019

Additional Information

Authorized Official

Authorized Official Last Name:
GAMPEL
Authorized Official First Name:
YURY
Authorized Official Middle Name:
Authorized Official Title or Position:
MANAGER
Authorized Official Telephone Number:
818-262-6423

Provider Taxonomy Codes

  • Taxonomy code: 2471V0106X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2085R0204X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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