Basic Information
| Provider Information | |||||||||
| NPI: | 1568658227 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | CHILDREN'S PHYSICIAN SERVICES OF SOUTH TEXAS | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | PLASTIC RECONSTRUCTIVE SURGICAL SERVICES OF SOUTH TEXAS | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 9336 | ||||||||
| Address2: | |||||||||
| City: | CORPUS CHRISTI | ||||||||
| State: | TX | ||||||||
| PostalCode: | 784699336 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3616941603 | ||||||||
| FaxNumber: | 3616946544 | ||||||||
| Practice Location | |||||||||
| Address1: | 3533 S ALAMEDA ST | ||||||||
| Address2: | |||||||||
| City: | CORPUS CHRISTI | ||||||||
| State: | TX | ||||||||
| PostalCode: | 784111721 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3616944444 | ||||||||
| FaxNumber: | 3616944445 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/17/2007 | ||||||||
| LastUpdateDate: | 12/14/2011 | ||||||||
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| AuthorizedOfficialLastName: | OBERMUELLER | ||||||||
| AuthorizedOfficialFirstName: | DALE | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | ADMINISTRATOR | ||||||||
| AuthorizedOfficialTelephone: | 3616945081 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | CHILDREN'S PHYSICIAN SERVICES OF SOUTH TEXAS | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208200000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Plastic Surgery |
ID Information
| ID | Type | State | Issuer | Description | 163786003 | 05 | TX | MEDICAID |