Basic Information
| Provider Information | |||||||||
| NPI: | 1891812483 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | COASTAL BEND WOMENS CENTER | ||||||||
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| Mailing Information | |||||||||
| Address1: | 7121 S PADRE ISLAND DR STE 200 | ||||||||
| Address2: | |||||||||
| City: | CORPUS CHRISTI | ||||||||
| State: | TX | ||||||||
| PostalCode: | 784124940 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3619936000 | ||||||||
| FaxNumber: | 3619851152 | ||||||||
| Practice Location | |||||||||
| Address1: | 7121 S PADRE ISLAND DR STE 200 | ||||||||
| Address2: | |||||||||
| City: | CORPUS CHRISTI | ||||||||
| State: | TX | ||||||||
| PostalCode: | 784124940 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3619936000 | ||||||||
| FaxNumber: | 3619851152 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/26/2007 | ||||||||
| LastUpdateDate: | 06/30/2010 | ||||||||
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| AuthorizedOfficialLastName: | RODRIGUEZ | ||||||||
| AuthorizedOfficialFirstName: | LEO | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | MANAGING PARTNER | ||||||||
| AuthorizedOfficialTelephone: | 3619936000 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207V00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology |
ID Information
| ID | Type | State | Issuer | Description | 00CB64 | 01 | BLUE CROSS BLUE SHIELD | OTHER | 112634401 | 05 | TX | MEDICAID |