1649391632 NPI number — SAMUEL R NEELEY MD PA

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 1649391632 NPI number — SAMUEL R NEELEY MD PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SAMUEL R NEELEY 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:
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:
1649391632
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/12/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 700447
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SAN ANTONIO
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
78270-0447
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
210-525-1668
Provider Business Mailing Address Fax Number:
210-525-1669

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
12446 WEST AVE
Provider Second Line Business Practice Location Address:
SUITE 200
Provider Business Practice Location Address City Name:
SAN ANTONIO
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
78216-2517
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
210-525-1668
Provider Business Practice Location Address Fax Number:
210-525-1669
Provider Enumeration Date:
04/03/2007

Additional Information

Authorized Official

Authorized Official Last Name:
NEELEY
Authorized Official First Name:
SAMUEL
Authorized Official Middle Name:
ROBERT
Authorized Official Title or Position:
PHYSICIAN
Authorized Official Telephone Number:
210-525-1668

Provider Taxonomy Codes

  • Taxonomy code: 261QM2500X , with the licence number:  E8757 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 208M00000X , with the licence number: E8757 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 0015PZ . This is a "BLUE CROSS" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 004203225 . This is a "AETNA HEALTHCARE" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 120344004 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".




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