Basic Information
| Provider Information | |||||||||
| NPI: | 1801841804 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PROFESSIONAL WOUND CARE SERVICES, P.A. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1814 | ||||||||
| Address2: | |||||||||
| City: | SAN ANTONIO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 782961814 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2105586288 | ||||||||
| FaxNumber: | 2105586289 | ||||||||
| Practice Location | |||||||||
| Address1: | 4499 MEDICAL DR | ||||||||
| Address2: | SUB-LEVEL 2 | ||||||||
| City: | SAN ANTONIO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 782293735 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2105754325 | ||||||||
| FaxNumber: | 2105754498 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/24/2006 | ||||||||
| LastUpdateDate: | 09/15/2015 | ||||||||
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| AuthorizedOfficialLastName: | SMITH | ||||||||
| AuthorizedOfficialFirstName: | JAMES | ||||||||
| AuthorizedOfficialMiddleName: | MARTIN | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 2105754334 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2083P0011X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Preventive Medicine | Undersea and Hyperbaric Medicine |
ID Information
| ID | Type | State | Issuer | Description | 171959301 | 05 | TX | MEDICAID |