Basic Information
| Provider Information | |||||||||
| NPI: | 1053919308 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CGN EPENT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5959 GATEWAY BLVD W STE 160 | ||||||||
| Address2: | |||||||||
| City: | EL PASO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 799253315 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9157795866 | ||||||||
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| Practice Location | |||||||||
| Address1: | 5959 GATEWAY BLVD W STE 160 | ||||||||
| Address2: | |||||||||
| City: | EL PASO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 799253315 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9157795866 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/09/2020 | ||||||||
| LastUpdateDate: | 12/01/2020 | ||||||||
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| AuthorizedOfficialLastName: | GONZALES | ||||||||
| AuthorizedOfficialFirstName: | ELIZABETH | ||||||||
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| AuthorizedOfficialTitleorPosition: | BILLING/CREDENTIALING SUPERVISOR | ||||||||
| AuthorizedOfficialTelephone: | 9157795866 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 12/01/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Y00000X | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Otolaryngology |
ID Information
| ID | Type | State | Issuer | Description | 153157602 | 05 | TX | MEDICAID | 326176001 | 05 | TX | MEDICAID | 118690001 | 05 | TX | MEDICAID |