Basic Information
| Provider Information | |||||||||
| NPI: | 1770988990 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CONVIVA MEDICAL CENTER MANAGEMENT OF TEXAS, P.A. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 711 NAVARRO ST STE 600 | ||||||||
| Address2: | |||||||||
| City: | SAN ANTONIO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 782051892 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5023023541 | ||||||||
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| Practice Location | |||||||||
| Address1: | 12602 TOEPPERWEIN RD STE 100 | ||||||||
| Address2: | |||||||||
| City: | LIVE OAK | ||||||||
| State: | TX | ||||||||
| PostalCode: | 782333204 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2106540030 | ||||||||
| FaxNumber: | 8552784550 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/30/2014 | ||||||||
| LastUpdateDate: | 02/15/2022 | ||||||||
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| AuthorizedOfficialLastName: | ROSELLO | ||||||||
| AuthorizedOfficialFirstName: | GEMMA | ||||||||
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| AuthorizedOfficialTitleorPosition: | AUTHORIZED REPRESENTATIVE | ||||||||
| AuthorizedOfficialTelephone: | 3055002109 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 02/15/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine | 208D00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | General Practice | 261QP2300X | N | Ambulatory Health Care Facilities | Clinic/Center | Primary Care | 207R00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 350315301 | 05 | TX | MEDICAID |