Basic Information
| Provider Information | |||||||||
| NPI: | 1851405559 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ANGELO GENERAL & THORACIC SURGERY | ||||||||
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| Mailing Information | |||||||||
| Address1: | 223 S ABE ST | ||||||||
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| City: | SAN ANGELO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 769036305 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3256557969 | ||||||||
| FaxNumber: | 3256557976 | ||||||||
| Practice Location | |||||||||
| Address1: | 2142 SUNSET DR | ||||||||
| Address2: | |||||||||
| City: | SAN ANGELO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 769046829 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3252454291 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/18/2006 | ||||||||
| LastUpdateDate: | 10/23/2007 | ||||||||
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| AuthorizedOfficialLastName: | SABORIO | ||||||||
| AuthorizedOfficialFirstName: | DAVID | ||||||||
| AuthorizedOfficialMiddleName: | V | ||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 3256557969 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208600000X | L9463 | TX | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Surgery |
ID Information
| ID | Type | State | Issuer | Description | 0040LT | 01 | TX | BC/BS OF TX GROUP# | OTHER |