1710021159 NPI number — CANCER CARE NETWORK OF SO TX - BOERNE

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 1710021159 NPI number — CANCER CARE NETWORK OF SO TX - BOERNE

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CANCER CARE NETWORK OF SO TX - BOERNE
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:
HEMATOLOGY ONCOLOGY ASSOCIATES OF SO. TX.
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:
1710021159
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4411 MEDICAL DR STE 100
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:
78229-3832
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
210-595-5326
Provider Business Mailing Address Fax Number:
210-614-8740

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
124 E BANDERA RD STE 301
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BOERNE
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
78006-2852
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
210-595-5326
Provider Business Practice Location Address Fax Number:
210-614-8740
Provider Enumeration Date:
02/19/2007

Additional Information

Authorized Official

Authorized Official Last Name:
LYONS
Authorized Official First Name:
ROGER
Authorized Official Middle Name:
M.
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
210-595-5326

Provider Taxonomy Codes

  • Taxonomy code: 207RH0003X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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