1821229717 NPI number — PRO PHYSICIANS CLINIC, PA

Table of content: (NPI 1821229717)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1821229717 NPI number — PRO PHYSICIANS CLINIC, PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PRO PHYSICIANS CLINIC, 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:
PRO PHYSICIANS CLINIC, PA
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:
1821229717
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/25/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
8019 S NEW BRAUNFELS STE 101
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:
78235-1069
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
210-816-4770
Provider Business Mailing Address Fax Number:
210-816-4771

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
12705 TOEPPERWEIN RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LIVE OAK
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
78233-3257
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
210-816-4770
Provider Business Practice Location Address Fax Number:
210-816-4771
Provider Enumeration Date:
07/27/2009

Additional Information

Authorized Official

Authorized Official Last Name:
TRYGGESTAD
Authorized Official First Name:
JON
Authorized Official Middle Name:
D
Authorized Official Title or Position:
CEO
Authorized Official Telephone Number:
817-886-8730

Provider Taxonomy Codes

  • Taxonomy code: 2085R0001X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 0A3406 . This is a "MEDICARE PTAN" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".




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