Basic Information
| Provider Information | |||||||||
| NPI: | 1124283627 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SAN ANTONIO PEDIATRIC ASSCIATES PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 315 N SAN SABA | ||||||||
| Address2: | #1075 | ||||||||
| City: | SAN ANTONIO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 782073155 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2102233543 | ||||||||
| FaxNumber: | 2102270282 | ||||||||
| Practice Location | |||||||||
| Address1: | 315 N SAN SABA STE 1075 | ||||||||
| Address2: | |||||||||
| City: | SAN ANTONIO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 782073155 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2102233543 | ||||||||
| FaxNumber: | 2102270282 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/23/2008 | ||||||||
| LastUpdateDate: | 07/23/2008 | ||||||||
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| AuthorizedOfficialLastName: | TSENG | ||||||||
| AuthorizedOfficialFirstName: | CLEVERT | ||||||||
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| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 2102233543 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 093706203 | 05 | TX | MEDICAID |