Basic Information
| Provider Information | |||||||||
| NPI: | 1710647565 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| 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: | 2103495777 | ||||||||
| FaxNumber: | 2104912868 | ||||||||
| Practice Location | |||||||||
| Address1: | 335 W. LOOP 1604 SOUTH | ||||||||
| Address2: | |||||||||
| City: | SAN ANTONIO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 78253 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2103495577 | ||||||||
| FaxNumber: | 2104912868 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/21/2021 | ||||||||
| LastUpdateDate: | 12/21/2021 | ||||||||
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| AuthorizedOfficialLastName: | RAMOS | ||||||||
| AuthorizedOfficialFirstName: | CHANTEL | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | PROFESSIONAL SERVICES SUPERVISOR | ||||||||
| AuthorizedOfficialTelephone: | 2103495577 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | TMC PROVIDER GROUP PLLC | ||||||||
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| NPICertificationDate: | 12/20/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QU0200X | Y | Ambulatory Health Care Facilities | Clinic/Center | Urgent Care |
ID Information
| ID | Type | State | Issuer | Description | 1053784660 | 01 | URGENT CARE | OTHER |