Basic Information
| Provider Information | |||||||||
| NPI: | 1467853051 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PAM SQUARED AT CORPUS CHRISTI, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1828 GOOD HOPE RD | ||||||||
| Address2: | SUITE 102 | ||||||||
| City: | ENOLA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 170251233 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7177319660 | ||||||||
| FaxNumber: | 7177319665 | ||||||||
| Practice Location | |||||||||
| Address1: | 600 ELIZABETH ST FL 3 | ||||||||
| Address2: | |||||||||
| City: | CORPUS CHRISTI | ||||||||
| State: | TX | ||||||||
| PostalCode: | 784042235 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3618813223 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 09/15/2014 | ||||||||
| LastUpdateDate: | 04/23/2018 | ||||||||
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| AuthorizedOfficialLastName: | MISITANO | ||||||||
| AuthorizedOfficialFirstName: | ANTHONY | ||||||||
| AuthorizedOfficialMiddleName: | F. | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 7177319660 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 282E00000X | Y | Hospitals | Long Term Care Hospital |
ID Information
| ID | Type | State | Issuer | Description | 346300201 | 05 | TX | MEDICAID | 346300202 | 05 | TX | MEDICAID |