Basic Information
| Provider Information | |||||||||
| NPI: | 1508171968 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CANCER CARE NETWORK OF SOUTH TEXAS, PA | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | FLORESVILLE - HOAST | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 100 NE LOOP 410 | ||||||||
| Address2: | SUITE 600 | ||||||||
| City: | SAN ANTONIO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 782164700 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2102426541 | ||||||||
| FaxNumber: | 2102125136 | ||||||||
| Practice Location | |||||||||
| Address1: | 497 10TH ST | ||||||||
| Address2: | STE. 102 | ||||||||
| City: | FLORESVILLE | ||||||||
| State: | TX | ||||||||
| PostalCode: | 781143179 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2105955300 | ||||||||
| FaxNumber: | 2105955301 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/10/2010 | ||||||||
| LastUpdateDate: | 03/22/2011 | ||||||||
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| AuthorizedOfficialLastName: | LYONS | ||||||||
| AuthorizedOfficialFirstName: | ROGER | ||||||||
| AuthorizedOfficialMiddleName: | M | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 2105955300 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RH0003X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Hematology & Oncology |
ID Information
| ID | Type | State | Issuer | Description | 109514302 | 05 | TX | MEDICAID |