Basic Information
| Provider Information | |||||||||
| NPI: | 1851368039 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SOUTH TEXAS RADIOLOGY GROUP PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | COLONNADE I, 9901 IH-10 WEST | ||||||||
| Address2: | SUITE 905 | ||||||||
| City: | SAN ANTONIO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 782305900 | ||||||||
| CountryCode: | US | ||||||||
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| Address1: | COLONNADE I, 9901 IH-10 WEST | ||||||||
| Address2: | SUITE 905 | ||||||||
| City: | SAN ANTONIO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 78230 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2106167700 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/07/2006 | ||||||||
| LastUpdateDate: | 06/27/2022 | ||||||||
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| AuthorizedOfficialLastName: | ZIEMKE | ||||||||
| AuthorizedOfficialFirstName: | BILL | ||||||||
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| AuthorizedOfficialTitleorPosition: | CHIEF EXECUTIVE OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 2106167700 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 06/27/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 121681401 | 05 | TX | MEDICAID | 121681402 | 01 | TX | CSHCN | OTHER |