1104919216 NPI number — ST. MARIE CLINIC, P.A.

Table of content: (NPI 1104919216)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1104919216 NPI number — ST. MARIE CLINIC, P.A.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ST. MARIE CLINIC, 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:
Provider Other Organization Name Type Code:
6
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:
1104919216
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/14/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
305 E EXPRESSWAY 83
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MISSION
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
78572-5560
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
956-585-7401
Provider Business Mailing Address Fax Number:
956-580-1788

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
305 E EXPRESSWAY 83
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MISSION
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
78572-5560
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
956-585-2009
Provider Business Practice Location Address Fax Number:
956-583-5833
Provider Enumeration Date:
10/02/2006

Additional Information

Authorized Official

Authorized Official Last Name:
CARRILLO
Authorized Official First Name:
EDUARDO
Authorized Official Middle Name:
Authorized Official Title or Position:
CEO/OWNER
Authorized Official Telephone Number:
956-585-7401

Provider Taxonomy Codes

  • Taxonomy code: 3336C0002X , with the licence number:  45-37380 , 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: 145560 . This is a "VENDOR DRUG NUMBER" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 45-37380 . This is a "NCPDP NUMBER" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".




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