Basic Information
| Provider Information | |||||||||
| NPI: | 1487965000 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CARDIOLOGY CLINIC OF SAN ANTONIO, PLLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4411 MEDICAL DR | ||||||||
| Address2: | SUITE #300 | ||||||||
| City: | SAN ANTONIO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 782293822 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2106145400 | ||||||||
| FaxNumber: | 2106145732 | ||||||||
| Practice Location | |||||||||
| Address1: | 4411 MEDICAL DR | ||||||||
| Address2: | SUITE #300 | ||||||||
| City: | SAN ANTONIO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 782293822 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2106145400 | ||||||||
| FaxNumber: | 2106145732 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/29/2010 | ||||||||
| LastUpdateDate: | 09/09/2019 | ||||||||
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| AuthorizedOfficialLastName: | CLOUD | ||||||||
| AuthorizedOfficialFirstName: | ROBERTA | ||||||||
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| AuthorizedOfficialTitleorPosition: | VICE PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 2105758501 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RC0001X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Clinical Cardiac Electrophysiology | 207RI0011X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Interventional Cardiology | 207RC0000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease |
ID Information
| ID | Type | State | Issuer | Description | H00040TV01 | 01 | TX | BCBS | OTHER | 218671001 | 05 | TX | MEDICAID | DR0519 | 01 | TX | MEDICARE RAILROAD | OTHER |