1225106875 NPI number — CHILDRENS CRITICAL CARE OF SAN ANTONIO PA

Table of content: (NPI 1225106875)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1225106875 NPI number — CHILDRENS CRITICAL CARE OF SAN ANTONIO PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CHILDRENS CRITICAL CARE OF SAN ANTONIO 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:
1225106875
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/16/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5925 KIRBY DR
Provider Second Line Business Mailing Address:
E354
Provider Business Mailing Address City Name:
HOUSTON
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
77005-2546
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
210-785-8282
Provider Business Mailing Address Fax Number:
210-785-8288

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5925 KIRBY DR
Provider Second Line Business Practice Location Address:
E354
Provider Business Practice Location Address City Name:
HOUSTON
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
77005-2546
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
210-785-8282
Provider Business Practice Location Address Fax Number:
210-785-8288
Provider Enumeration Date:
12/01/2006

Additional Information

Authorized Official

Authorized Official Last Name:
MARCUM
Authorized Official First Name:
JOHN
Authorized Official Middle Name:
W
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
210-785-8282

Provider Taxonomy Codes

  • Taxonomy code: 2080P0203X , with the licence number:  M3009 , 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: 178280701 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 0014NH . This is a "BCBS" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".




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