1477851970 NPI number — WELLMED MEDICAL GROUP, P.A.

Table of content: (NPI 1477851970)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1477851970 NPI number — WELLMED MEDICAL GROUP, P.A.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
WELLMED MEDICAL GROUP, 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:
WELLMED HOLLY ROAD SENIOR CLINIC
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:
1477851970
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/24/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
8637 FREDERICKSBURG RD STE 360
Provider Second Line Business Mailing Address:
ATTN: DIRECTOR OF ACCOUNTS RECEIVABLE
Provider Business Mailing Address City Name:
SAN ANTONIO
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
78240-1285
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
210-877-7570
Provider Business Mailing Address Fax Number:
210-641-2235

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5402 HOLLY RD
Provider Second Line Business Practice Location Address:
SUITE 102
Provider Business Practice Location Address City Name:
CORPUS CHRISTI
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
78411-4645
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
361-883-9688
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
03/08/2011

Additional Information

Authorized Official

Authorized Official Last Name:
HERNANDEZ
Authorized Official First Name:
CARLOS
Authorized Official Middle Name:
O
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
210-877-7570

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 207R00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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





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