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
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 000103 | TX | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |   | 208000000X | 000103 | TX | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics |   | 261QR1300X |   | TX | Y |   | Ambulatory Health Care Facilities | Clinic/Center | Rural Health |
ID Information
ID | Type | State | Issuer | Description | 091887201 | 05 | TX |   | MEDICAID | 091887202 | 05 | TX |   | MEDICAID |