Basic Information
| Provider Information | |||||||||
| NPI: | 1952390841 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MASON | ||||||||
| FirstName: | PHILLIP | ||||||||
| MiddleName: | E | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | MASON | ||||||||
| OtherFirstName: | PHILLIP | ||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | MD | ||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 21 SPURS LN | ||||||||
| Address2: | 230B | ||||||||
| City: | SAN ANTONIO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 782401669 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2106907400 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 21 SPURS LN | ||||||||
| Address2: | 230B | ||||||||
| City: | SAN ANTONIO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 782401669 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2106907400 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/14/2005 | ||||||||
| LastUpdateDate: | 10/19/2015 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207PE0004X | L5039 | TX | N | Allopathic & Osteopathic Physicians | Emergency Medicine | Emergency Medical Services | 207PE0004X | 35.093611 | OH | N | Allopathic & Osteopathic Physicians | Emergency Medicine | Emergency Medical Services | 207P00000X | L5039 | TX | N | Allopathic & Osteopathic Physicians | Emergency Medicine | 207RC0200X | L5039 | TX | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Critical Care Medicine |
ID Information
| ID | Type | State | Issuer | Description | 154188004 | 05 | TX | MEDICAID | 2493798 | 05 | OH | MEDICAID | 154188002 | 05 | TX | MEDICAID | 154188003 | 05 | TX | MEDICAID |