Basic Information
| Provider Information | |||||||||
| NPI: | 1104338052 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | DOCTORS HOSPITAL AT RENAISSANCE, LTD | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | RENAISSANCE TRANSPLANT INSTITUTE | ||||||||
| OtherOrganizationType: | 5 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 3293 | ||||||||
| Address2: | |||||||||
| City: | MCALLEN | ||||||||
| State: | TX | ||||||||
| PostalCode: | 785023293 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9563628677 | ||||||||
| FaxNumber: | 9563623372 | ||||||||
| Practice Location | |||||||||
| Address1: | 1100 E DOVE AVE STE 200 | ||||||||
| Address2: | |||||||||
| City: | MCALLEN | ||||||||
| State: | TX | ||||||||
| PostalCode: | 785044681 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9563625433 | ||||||||
| FaxNumber: | 9563622420 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/01/2017 | ||||||||
| LastUpdateDate: | 11/10/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | MATHEWS | ||||||||
| AuthorizedOfficialFirstName: | PATRICK | ||||||||
| AuthorizedOfficialMiddleName: | JOSEPH | ||||||||
| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 9563623096 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | DOCTORS HOSPITAL AT RENAISSANCE, LTD | ||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 11/09/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 204F00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Transplant Surgery |
ID Information
| ID | Type | State | Issuer | Description | 160709501 | 05 | TX | MEDICAID | HH1032 | 01 | TX | BLUE CROSS | OTHER |