Basic Information
| Provider Information | |||||||||
| NPI: | 1306258397 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SAUSHEC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1634 VORMIS VW | ||||||||
| Address2: | |||||||||
| City: | SAN ANTONIO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 782515030 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 3551 ROGER BROOKE DR | ||||||||
| Address2: | |||||||||
| City: | JBSA FT SAM HOUSTON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 782344504 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2109166463 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/24/2014 | ||||||||
| LastUpdateDate: | 05/24/2014 | ||||||||
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| AuthorizedOfficialLastName: | PORTER | ||||||||
| AuthorizedOfficialFirstName: | KATHY | ||||||||
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| AuthorizedOfficialTitleorPosition: | PROGRAM DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 2109166463 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 286500000X | Y | Hospitals | Military Hospital |
No ID Information.