Basic Information
| Provider Information | |||||||||
| NPI: | 1164454310 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SAN ANTONIO PEDIATRIC ASSOC PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 120427 | ||||||||
| Address2: | |||||||||
| City: | SAN ANTONIO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 782120427 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2102233543 | ||||||||
| FaxNumber: | 2102270282 | ||||||||
| Practice Location | |||||||||
| Address1: | 315 N SAN SABA | ||||||||
| Address2: | #1075 | ||||||||
| City: | SAN ANTONIO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 782073154 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2102233543 | ||||||||
| FaxNumber: | 2102270282 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/07/2006 | ||||||||
| LastUpdateDate: | 03/23/2010 | ||||||||
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| AuthorizedOfficialLastName: | RIOJAS | ||||||||
| AuthorizedOfficialFirstName: | RICARDO | ||||||||
| AuthorizedOfficialMiddleName: | A | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 2102421795 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 017783401 | 05 | TX | MEDICAID |