1558643478 NPI number — CANOVA INTERNAL MEDICINE CLINIC,PA.

Table of content: (NPI 1558643478)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1558643478 NPI number — CANOVA INTERNAL MEDICINE CLINIC,PA.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CANOVA INTERNAL MEDICINE CLINIC,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:
1558643478
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/07/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
6602 POLARIS DRIVE
Provider Second Line Business Mailing Address:
STE 5
Provider Business Mailing Address City Name:
LAREDO
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
78041
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
956-791-1414
Provider Business Mailing Address Fax Number:
956-796-9495

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
6602 POLARIS DR.
Provider Second Line Business Practice Location Address:
STE 5
Provider Business Practice Location Address City Name:
LAREDO
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
78041
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
956-791-1414
Provider Business Practice Location Address Fax Number:
956-796-9495
Provider Enumeration Date:
09/16/2011

Additional Information

Authorized Official

Authorized Official Last Name:
CANOVA
Authorized Official First Name:
EDUARDO
Authorized Official Middle Name:
CARLOS
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
956-791-1414

Provider Taxonomy Codes

  • Taxonomy code: 207R00000X , with the licence number:  P0706 , 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: B0183294 . This is a "DPS" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: P0706 . This is a "TX-LICENSE" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".




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