Basic Information
| Provider Information | |||||||||
| NPI: | 1255760054 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | QUALITY ACUTE CARE, PA | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | MAIN STREET URGENT CARE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 1421 S MAIN ST | ||||||||
| Address2: | SUITE #111 | ||||||||
| City: | BOERNE | ||||||||
| State: | TX | ||||||||
| PostalCode: | 780063321 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8302499995 | ||||||||
| FaxNumber: | 8302499868 | ||||||||
| Practice Location | |||||||||
| Address1: | 1421 S MAIN ST | ||||||||
| Address2: | SUITE #111 | ||||||||
| City: | BOERNE | ||||||||
| State: | TX | ||||||||
| PostalCode: | 780063321 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8302499995 | ||||||||
| FaxNumber: | 8302499868 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/02/2013 | ||||||||
| LastUpdateDate: | 09/08/2016 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | DEDMON | ||||||||
| AuthorizedOfficialFirstName: | MELISSA | ||||||||
| AuthorizedOfficialMiddleName: | THURMOND | ||||||||
| AuthorizedOfficialTitleorPosition: | ADMINISTRATIVE MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 8302499995 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | K8182 | TX | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Emergency Medicine | 363A00000X | PA02389 | TX | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 261QU0200X | Y | Ambulatory Health Care Facilities | Clinic/Center | Urgent Care |
ID Information
| ID | Type | State | Issuer | Description | 342847601 | 05 | TX | MEDICAID |