Basic Information
| Provider Information | |||||||||
| NPI: | 1053468777 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | AFFILIATES FOR WOMENS HEALTH PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1602 ROCK PRAIRIE RD | ||||||||
| Address2: | SUITE 430 | ||||||||
| City: | COLLEGE STATION | ||||||||
| State: | TX | ||||||||
| PostalCode: | 778458306 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9796930737 | ||||||||
| FaxNumber: | 9796937442 | ||||||||
| Practice Location | |||||||||
| Address1: | 1602 ROCK PRAIRIE RD | ||||||||
| Address2: | SUITE 430 | ||||||||
| City: | COLLEGE STATION | ||||||||
| State: | TX | ||||||||
| PostalCode: | 778458306 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9796930737 | ||||||||
| FaxNumber: | 9796937442 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/04/2007 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | ANDERSON | ||||||||
| AuthorizedOfficialFirstName: | CHARLES | ||||||||
| AuthorizedOfficialMiddleName: | R | ||||||||
| AuthorizedOfficialTitleorPosition: | PHYSICIAN PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 9796930737 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207VG0400X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | Gynecology |
ID Information
| ID | Type | State | Issuer | Description | 081516902 | 05 | TX | MEDICAID |