Basic Information
Provider Information | |||||||||
NPI: | 1336353309 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | BEXAR COUNTY HOSPITAL DISTRICT | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | UNIVERSITY HEALTH SYSTEM | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 4502 MEDICAL DR | ||||||||
Address2: | MAIL STOP 72-1 | ||||||||
City: | SAN ANTONIO | ||||||||
State: | TX | ||||||||
PostalCode: | 782294402 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2103584000 | ||||||||
FaxNumber: | 2103584745 | ||||||||
Practice Location | |||||||||
Address1: | 903 W MARTIN ST | ||||||||
Address2: | MAIL STOP 49-2 | ||||||||
City: | SAN ANTONIO | ||||||||
State: | TX | ||||||||
PostalCode: | 782070903 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2103588255 | ||||||||
FaxNumber: | 2103583347 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/09/2007 | ||||||||
LastUpdateDate: | 06/18/2015 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | HURLEY | ||||||||
AuthorizedOfficialFirstName: | REED | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | EXECUTIVE VICE PRESIDENT CFO | ||||||||
AuthorizedOfficialTelephone: | 2103582101 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | MR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QF0050X |   |   | Y |   | Ambulatory Health Care Facilities | Clinic/Center | Family Planning, Non-Surgical |
ID Information
ID | Type | State | Issuer | Description | 126881504 | 05 | TX |   | MEDICAID |