Basic Information
| Provider Information | |||||||||
| NPI: | 1619071875 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | SOUTH TEXAS VETERANS HEALTHCARE SYSTEM | ||||||||
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| Mailing Information | |||||||||
| Address1: | 7400 MERTON MINTER BOULEVARD | ||||||||
| Address2: | |||||||||
| City: | SAN ANTONIO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 78229 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2106175300 | ||||||||
| FaxNumber: | 2109493326 | ||||||||
| Practice Location | |||||||||
| Address1: | 112 DOVE MOUNTAIN DR | ||||||||
| Address2: | |||||||||
| City: | BOERNE | ||||||||
| State: | TX | ||||||||
| PostalCode: | 780067868 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8305374088 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 09/11/2006 | ||||||||
| LastUpdateDate: | 07/21/2022 | ||||||||
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| AuthorizedOfficialLastName: | GROTA | ||||||||
| AuthorizedOfficialFirstName: | PHILIP | ||||||||
| AuthorizedOfficialMiddleName: | A. | ||||||||
| AuthorizedOfficialTitleorPosition: | SUPERVISOR, SOCIAL WORK SERVICE | ||||||||
| AuthorizedOfficialTelephone: | 2106175300 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| AuthorizedOfficialCredential: | LCSW | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 282N00000X | Y | Hospitals | General Acute Care Hospital |
ID Information
| ID | Type | State | Issuer | Description | 00341 | 01 | TX | SOCIAL WORK LICENSE | OTHER |