1518265891 NPI number — WELLMED MEDICAL GROUP, P.A.

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 1518265891 NPI number — WELLMED MEDICAL GROUP, P.A.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
WELLMED MEDICAL GROUP, 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:
WELLMED SENIOR CLINIC AT MIDTOWN
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:
1518265891
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/24/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
8637 FREDERICKSBURG ROAD, SUITE 360
Provider Second Line Business Mailing Address:
ATTN: DIRECTOR OF ACCOUNTS RECEIVABLE
Provider Business Mailing Address City Name:
SAN ANTONIO
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
78240-1285
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
210-877-7570
Provider Business Mailing Address Fax Number:
210-641-2235

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3708 JEFFERSON ST
Provider Second Line Business Practice Location Address:
SUITE A
Provider Business Practice Location Address City Name:
AUSTIN
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
78731-6206
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
512-459-6503
Provider Business Practice Location Address Fax Number:
512-454-7453
Provider Enumeration Date:
03/10/2011

Additional Information

Authorized Official

Authorized Official Last Name:
HERNANDEZ
Authorized Official First Name:
CARLOS
Authorized Official Middle Name:
O
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
210-877-7570

Provider Taxonomy Codes

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

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





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