Basic Information
Provider Information
NPI: 1811999337
EntityType: 2
ReplacementNPI:  
OrganizationName: GONZALES HEALTHCARE SYSTEMS
LastName:  
FirstName:  
MiddleName:  
NamePrefix:  
NameSuffix:  
Credential:  
OtherOrganizationName: SIEVERS MEDICAL CLINIC - WAELDER
OtherOrganizationType: 3
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: PO BOX 587
Address2:  
City: GONZALES
State: TX
PostalCode: 786290587
CountryCode: US
TelephoneNumber: 8306727581
FaxNumber: 8306722401
Practice Location
Address1: 1818 E US HWY 90
Address2:  
City: WAELDER
State: TX
PostalCode: 78959
CountryCode: US
TelephoneNumber: 8306727581
FaxNumber: 8306722401
Other Information
ProviderEnumerationDate: 08/15/2005
LastUpdateDate: 10/21/2022
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode:  
AuthorizedOfficialLastName: LACOSTE
AuthorizedOfficialFirstName: MICHAEL
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition: CEO ADMINISTRATOR
AuthorizedOfficialTelephone: 8306727581
IsSoleProprietor:  
IsOrganizationSubpart: Y
ParentOrganizationLBN: GONZALES HEALTHCARE SYSTEMS
AuthorizedOfficialNamePrefix: MR.
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  
NPICertificationDate: 10/21/2022

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
207Q00000X000103TXN193200000X MULTI-SPECIALTY GROUPAllopathic & Osteopathic PhysiciansFamily Medicine 
208000000X000103TXN193200000X MULTI-SPECIALTY GROUPAllopathic & Osteopathic PhysiciansPediatrics 
261QR1300X TXY Ambulatory Health Care FacilitiesClinic/CenterRural Health

ID Information
IDTypeStateIssuerDescription
09188720105TX MEDICAID
09188720205TX MEDICAID


Home