Basic Information
| Provider Information | |||||||||
| NPI: | 1598120388 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | TMC PROVIDER GROUP PLLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 13722 EMBASSY ROW | ||||||||
| Address2: | |||||||||
| City: | SAN ANTONIO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 782162000 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2103495577 | ||||||||
| FaxNumber: | 2104912868 | ||||||||
| Practice Location | |||||||||
| Address1: | 1007 NE LOOP 410 | ||||||||
| Address2: | |||||||||
| City: | SAN ANTONIO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 782091205 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2108215598 | ||||||||
| FaxNumber: | 2108290125 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/21/2015 | ||||||||
| LastUpdateDate: | 12/21/2015 | ||||||||
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| AuthorizedOfficialLastName: | SWIFT | ||||||||
| AuthorizedOfficialFirstName: | BERNARD | ||||||||
| AuthorizedOfficialMiddleName: | T | ||||||||
| AuthorizedOfficialTitleorPosition: | MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 2104034210 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | TMC PROVIDER GROUP PLLC | ||||||||
| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | JR. | ||||||||
| AuthorizedOfficialCredential: | DO | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | F0031 | TX | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.