Basic Information
| Provider Information | |||||||||
| NPI: | 1801913462 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | CANCER CARE NETWORK OF SOUTH TEXAS PA | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | MARBLE FALLS II - S.A. TUMOR & BLOOD CLINIC | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 100 NE LOOP 410 | ||||||||
| Address2: | SUITE 600 | ||||||||
| City: | SAN ANTONIO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 782164700 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2102426541 | ||||||||
| FaxNumber: | 2102125136 | ||||||||
| Practice Location | |||||||||
| Address1: | 1100 MISSION HILLS | ||||||||
| Address2: | #200 | ||||||||
| City: | MARBLE FALLS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 78654 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8306935497 | ||||||||
| FaxNumber: | 8306939356 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/26/2007 | ||||||||
| LastUpdateDate: | 10/28/2011 | ||||||||
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| AuthorizedOfficialLastName: | GORDON | ||||||||
| AuthorizedOfficialFirstName: | DAVID | ||||||||
| AuthorizedOfficialMiddleName: | H | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 2105456972 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | M.D. | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RH0003X | E9664 | TX | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Hematology & Oncology |
No ID Information.