Basic Information
| Provider Information | |||||||||
| NPI: | 1336274380 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ST MARIE CLINIC PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 305 E EXPRESSWAY 83 | ||||||||
| Address2: | |||||||||
| City: | MISSION | ||||||||
| State: | TX | ||||||||
| PostalCode: | 785725560 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9565857401 | ||||||||
| FaxNumber: | 9565801788 | ||||||||
| Practice Location | |||||||||
| Address1: | 305 E EXPRESSWAY 83 | ||||||||
| Address2: | |||||||||
| City: | MISSION | ||||||||
| State: | TX | ||||||||
| PostalCode: | 785725560 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9565857401 | ||||||||
| FaxNumber: | 9565801788 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/22/2007 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | CARRILLO | ||||||||
| AuthorizedOfficialFirstName: | EDUARDO | ||||||||
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| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 9565857401 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2080A0000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics | Adolescent Medicine |
No ID Information.