Basic Information
| Provider Information | |||||||||
| NPI: | 1013098607 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | EL PASO COLON AND RECTAL CLINIC PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4849 N MESA ST STE 201 | ||||||||
| Address2: | |||||||||
| City: | EL PASO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 799125919 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9153516600 | ||||||||
| FaxNumber: | 9153516601 | ||||||||
| Practice Location | |||||||||
| Address1: | 900 CHELSEA ST | ||||||||
| Address2: | |||||||||
| City: | EL PASO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 799034927 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9155444042 | ||||||||
| FaxNumber: | 9158577809 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/18/2006 | ||||||||
| LastUpdateDate: | 12/27/2018 | ||||||||
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| AuthorizedOfficialLastName: | GOMEZ | ||||||||
| AuthorizedOfficialFirstName: | CHRISTINE | ||||||||
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| AuthorizedOfficialTitleorPosition: | OFFICE MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 9155444042 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MISS | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208C00000X | H9957 | TX | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Colon & Rectal Surgery | 208C00000X | N6538 | TX | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Colon & Rectal Surgery | 208600000X | N6538 | TX | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Surgery | 208600000X | H9957 | TX | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Surgery |
ID Information
| ID | Type | State | Issuer | Description | 84633301 | 05 | TX | MEDICAID |