Basic Information
| Provider Information | |||||||||
| NPI: | 1487764908 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | NORTHEAST OB/GYN ASSOCIATES, PLLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1210 ARION PKWY | ||||||||
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| City: | SAN ANTONIO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 782162880 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2105906195 | ||||||||
| FaxNumber: | 2106505975 | ||||||||
| Practice Location | |||||||||
| Address1: | 8715 VILLAGE DR | ||||||||
| Address2: | SUITE 410 | ||||||||
| City: | SAN ANTONIO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 782175405 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2105906195 | ||||||||
| FaxNumber: | 2106505975 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/30/2006 | ||||||||
| LastUpdateDate: | 03/04/2013 | ||||||||
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| AuthorizedOfficialLastName: | AKRIGHT | ||||||||
| AuthorizedOfficialFirstName: | BRUCE | ||||||||
| AuthorizedOfficialMiddleName: | D. | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 2106509978 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | CONSULTANTS IN WOMENS HEALTH | ||||||||
| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207V00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology |
ID Information
| ID | Type | State | Issuer | Description | 082726301 | 05 | TX | MEDICAID |