Basic Information
| Provider Information | |||||||||
| NPI: | 1902398365 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SOUTH TEXAS SKIN CANCER CENTER LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2632 BROADWAY ST STE 300S | ||||||||
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| City: | SAN ANTONIO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 782151137 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2105586234 | ||||||||
| FaxNumber: | 2104465039 | ||||||||
| Practice Location | |||||||||
| Address1: | 2632 BROADWAY ST | ||||||||
| Address2: | STE 300 SOUTH | ||||||||
| City: | SAN ANTONIO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 782151137 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2105586234 | ||||||||
| FaxNumber: | 2104465039 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/01/2018 | ||||||||
| LastUpdateDate: | 01/30/2020 | ||||||||
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| AuthorizedOfficialLastName: | FLORES | ||||||||
| AuthorizedOfficialFirstName: | STEPHANIE | ||||||||
| AuthorizedOfficialMiddleName: | A. | ||||||||
| AuthorizedOfficialTitleorPosition: | BILLING SUPERVISOR | ||||||||
| AuthorizedOfficialTelephone: | 2108901508 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 01/30/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207ND0101X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Dermatology | MOHS-Micrographic Surgery |
ID Information
| ID | Type | State | Issuer | Description | 1902398365 | 05 | TX | MEDICAID |