1033381447 NPI number — NORTHEAST INTERNAL MEDICAL ASSOCIATES PLLC

Table of content: (NPI 1033381447)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1033381447 NPI number — NORTHEAST INTERNAL MEDICAL ASSOCIATES PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
NORTHEAST INTERNAL MEDICAL ASSOCIATES PLLC
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:
1033381447
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/28/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
12602 TOEPPERWEIN RD
Provider Second Line Business Mailing Address:
SUITE #100
Provider Business Mailing Address City Name:
SAN ANTONIO
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
78233-3269
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
210-650-9669
Provider Business Mailing Address Fax Number:
210-650-0750

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
12602 TOEPPERWEIN RD
Provider Second Line Business Practice Location Address:
SUITE #100
Provider Business Practice Location Address City Name:
SAN ANTONIO
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
78233-3269
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
210-650-9669
Provider Business Practice Location Address Fax Number:
210-650-0750
Provider Enumeration Date:
03/25/2008

Additional Information

Authorized Official

Authorized Official Last Name:
CLOUD
Authorized Official First Name:
ROBERTA
Authorized Official Middle Name:
S.
Authorized Official Title or Position:
VICE PRESIDENT
Authorized Official Telephone Number:
210-575-8505

Provider Taxonomy Codes

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

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

  • Identifier: DN3280 . This is a "RAILROAD" identifier . This identifiers is of the category "OTHER".
  • Identifier: 0075RH . This is a "BCBS" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 1980823-01 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".




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