Basic Information
| Provider Information | |||||||||
| NPI: | 1528071123 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| 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: | 10900 N 103RD ST | ||||||||
| Address2: | |||||||||
| City: | MISSION | ||||||||
| State: | TX | ||||||||
| PostalCode: | 785730979 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9565837744 | ||||||||
| FaxNumber: | 9565837747 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/14/2006 | ||||||||
| LastUpdateDate: | 01/16/2009 | ||||||||
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| AuthorizedOfficialLastName: | CARRLLO | ||||||||
| AuthorizedOfficialFirstName: | EDUARDO | ||||||||
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| AuthorizedOfficialTitleorPosition: | OWNER/CEO | ||||||||
| AuthorizedOfficialTelephone: | 9565837744 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QR0400X | Y | Ambulatory Health Care Facilities | Clinic/Center | Rehabilitation |
ID Information
| ID | Type | State | Issuer | Description | 676630 | 01 | TX | MEDICARE PROVIDER # | OTHER |