Basic Information
| Provider Information | |||||||||
| NPI: | 1629191176 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | RIVERWALK CLINIC, LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | ALAMO CITY MEDICAL GROUP | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5080 SPECTRUM DR | ||||||||
| Address2: | SUITE 1200 WEST TOWER | ||||||||
| City: | ADDISON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 750014648 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 1045 CENTRAL PARKWAY NORTH | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | SAN ANTONIO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 782325024 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2102721741 | ||||||||
| FaxNumber: | 2102721747 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/09/2007 | ||||||||
| LastUpdateDate: | 06/12/2013 | ||||||||
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| AuthorizedOfficialLastName: | FOGARTY | ||||||||
| AuthorizedOfficialFirstName: | WILLIAM | ||||||||
| AuthorizedOfficialMiddleName: | TOM | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 9723648000 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | J3984 | TX | N | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine | 261QU0200X | J3984 | TX | Y | Ambulatory Health Care Facilities | Clinic/Center | Urgent Care |
ID Information
| ID | Type | State | Issuer | Description | 199345301 | 05 | TX | MEDICAID |