Basic Information
| Provider Information | |||||||||
| NPI: | 1164476933 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | NOVAMED SURGERY CENTER OF SAN ANTONIO LP | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | AMERICAN SURGERY CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 12838 VISTA DEL NORTE | ||||||||
| Address2: | |||||||||
| City: | SAN ANTONIO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 78216 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8666317890 | ||||||||
| FaxNumber: | 2106927890 | ||||||||
| Practice Location | |||||||||
| Address1: | 12838 VISTA DEL NORTE | ||||||||
| Address2: | |||||||||
| City: | SAN ANTONIO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 78216 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8666317890 | ||||||||
| FaxNumber: | 2106927890 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/19/2006 | ||||||||
| LastUpdateDate: | 02/25/2020 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | BALDOCK | ||||||||
| AuthorizedOfficialFirstName: | JENNIFER | ||||||||
| AuthorizedOfficialMiddleName: | BOYD | ||||||||
| AuthorizedOfficialTitleorPosition: | OFFICER AND AUTHORIZED OFFICIAL | ||||||||
| AuthorizedOfficialTelephone: | 6152345935 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 02/25/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QA1903X | 008352 | TX | Y | Ambulatory Health Care Facilities | Clinic/Center | Ambulatory Surgical |
ID Information
| ID | Type | State | Issuer | Description | 184266801 | 05 | TX | MEDICAID | P00339215 | 01 | RR MEDICARE | OTHER |