1972762284 NPI number — CANCER CARE NETWORK OF SOUTH TEXAS PA

Table of content: (NPI 1972762284)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1972762284 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:
1972762284
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/27/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
100 NE LOOP 410
Provider Second Line Business Mailing Address:
SUITE 600
Provider Business Mailing Address City Name:
SAN ANTONIO
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
78216-4700
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
210-242-6541
Provider Business Mailing Address Fax Number:
210-212-5136

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2130 NE LOOP 410
Provider Second Line Business Practice Location Address:
SUITE 100
Provider Business Practice Location Address City Name:
SAN ANTONIO
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
78217-4659
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
210-656-7177
Provider Business Practice Location Address Fax Number:
210-656-3687
Provider Enumeration Date:
06/03/2008

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:
210-656-7177

Provider Taxonomy Codes

  • Taxonomy code: 2085R0203X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2085R0001X ; 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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