Basic Information
| Provider Information | |||||||||
| NPI: | 1013916287 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | GONZALES HEALTHCARE SYSTEMS | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
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| OtherOrganizationName: | SIEVERS MEDICAL CLINIC | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 587 | ||||||||
| Address2: | |||||||||
| City: | GONZALES | ||||||||
| State: | TX | ||||||||
| PostalCode: | 786290587 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8306727581 | ||||||||
| FaxNumber: | 8306722401 | ||||||||
| Practice Location | |||||||||
| Address1: | 1110 N SARAH DEWITT DR | ||||||||
| Address2: | |||||||||
| City: | GONZALES | ||||||||
| State: | TX | ||||||||
| PostalCode: | 786293311 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8306727581 | ||||||||
| FaxNumber: | 8306722401 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/19/2005 | ||||||||
| LastUpdateDate: | 10/21/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | LACOSTE | ||||||||
| AuthorizedOfficialFirstName: | MICHAEL | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CEO ADMINISTRATOR | ||||||||
| AuthorizedOfficialTelephone: | 8306727581 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | GONZALES HEALTHCARE SYSTEMS | ||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 10/21/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 000130 | TX | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine | 208000000X | 000103 | TX | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics | 261QR1300X | TX | Y | Ambulatory Health Care Facilities | Clinic/Center | Rural Health |
ID Information
| ID | Type | State | Issuer | Description | 130781104 | 05 | TX | MEDICAID | 130781103 | 05 | TX | MEDICAID | 130781102 | 05 | TX | MEDICAID |