1417065947 NPI number — CANCER CARE NETWORK OF SOUTH TEXAS PA

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 1417065947 NPI number — CANCER CARE NETWORK OF SOUTH TEXAS PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CANCER CARE NETWORK OF SOUTH TEXAS 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:
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:
1417065947
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/26/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
8715 VILLAGE DR
Provider Second Line Business Mailing Address:
SUITE#514
Provider Business Mailing Address City Name:
SAN ANTONIO
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
78217-5405
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
210-637-0641
Provider Business Mailing Address Fax Number:
210-637-0613

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
8715 VILLAGE DR
Provider Second Line Business Practice Location Address:
SUITE#514
Provider Business Practice Location Address City Name:
SAN ANTONIO
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
78217-5405
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
210-637-0641
Provider Business Practice Location Address Fax Number:
210-637-0613
Provider Enumeration Date:
08/25/2006

Additional Information

Authorized Official

Authorized Official Last Name:
GORDON
Authorized Official First Name:
DAVID
Authorized Official Middle Name:
H
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
210-545-6972

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)

  • Identifier: 109514302 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 00U40Q . This is a "BLUECROSS/BLUESHIELD TX" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".




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