Basic Information
Provider Information | |||||||||
NPI: | 1326070988 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | GATEWAY COMMUNITY HEALTH CENTER, INC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | GATEWAY COMMUNITY HEALTH CENTER, INC. | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1515 PAPPAS ST | ||||||||
Address2: |   | ||||||||
City: | LAREDO | ||||||||
State: | TX | ||||||||
PostalCode: | 780411705 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9567958100 | ||||||||
FaxNumber: | 9567186294 | ||||||||
Practice Location | |||||||||
Address1: | 1515 PAPPAS ST | ||||||||
Address2: |   | ||||||||
City: | LAREDO | ||||||||
State: | TX | ||||||||
PostalCode: | 780411705 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9567958100 | ||||||||
FaxNumber: | 9567186294 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/06/2006 | ||||||||
LastUpdateDate: | 09/07/2010 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | TREVINO | ||||||||
AuthorizedOfficialFirstName: | MIGUEL | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | CEO | ||||||||
AuthorizedOfficialTelephone: | 9565233646 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | MR. | ||||||||
AuthorizedOfficialNameSuffix: | JR. | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X |   |   | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |   | 261QF0400X |   | TX | Y |   | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) |
ID Information
ID | Type | State | Issuer | Description | 092953101 | 05 | TX |   | MEDICAID | 081896501 | 05 | TX |   | MEDICAID |