Basic Information
| Provider Information | |||||||||
| NPI: | 1700067808 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | FAMILY SPECIALISTS MEDICAL CENTER PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2401 SE AUGUSTA SQ | ||||||||
| Address2: | |||||||||
| City: | MCALLEN | ||||||||
| State: | TX | ||||||||
| PostalCode: | 785031105 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9565851564 | ||||||||
| FaxNumber: | 9565852830 | ||||||||
| Practice Location | |||||||||
| Address1: | 1605 E EXPRESSWAY 83 | ||||||||
| Address2: | SUITE D | ||||||||
| City: | MISSION | ||||||||
| State: | TX | ||||||||
| PostalCode: | 785726616 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9565851564 | ||||||||
| FaxNumber: | 9565852830 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/16/2007 | ||||||||
| LastUpdateDate: | 03/29/2012 | ||||||||
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| AuthorizedOfficialLastName: | GOMEZ | ||||||||
| AuthorizedOfficialFirstName: | FELIPE | ||||||||
| AuthorizedOfficialMiddleName: | DE JESUS | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 9565851564 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | J4825 | TX | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 0031DM | 01 | TX | BCBS | OTHER | 092297301 | 05 | TX | MEDICAID |