Provider Demographics
NPI:1033661913
Name:PVDM-RIM ED
Entity Type:Organization
Organization Name:PVDM-RIM ED
Other - Org Name:FULL SPECTRUM EMERGENCY ROOM AT THE RIM
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:PETER
Authorized Official - Middle Name:
Authorized Official - Last Name:VAN DELDEN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:210-445-4450
Mailing Address - Street 1:PO BOX 690804
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78269-0804
Mailing Address - Country:US
Mailing Address - Phone:210-530-1040
Mailing Address - Fax:210-530-1187
Practice Address - Street 1:18007 W IH 10
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78257
Practice Address - Country:US
Practice Address - Phone:210-530-1040
Practice Address - Fax:210-530-1187
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-10-26
Last Update Date:2022-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX160291261QE0002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QE0002XAmbulatory Health Care FacilitiesClinic/CenterEmergency Care