Provider Demographics
NPI:1043379597
Name:SAN AUGUSTINE FAMILY PRACTICE PA
Entity Type:Organization
Organization Name:SAN AUGUSTINE FAMILY PRACTICE PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLING & COLLECTIONS
Authorized Official - Prefix:
Authorized Official - First Name:STEPHANIE
Authorized Official - Middle Name:DEANN
Authorized Official - Last Name:ANDERSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:936-275-9910
Mailing Address - Street 1:200 E LIVINGSTON ST
Mailing Address - Street 2:
Mailing Address - City:SAN AUGUSTINE
Mailing Address - State:TX
Mailing Address - Zip Code:75972-2028
Mailing Address - Country:US
Mailing Address - Phone:936-275-9910
Mailing Address - Fax:936-275-9710
Practice Address - Street 1:200 E LIVINGSTON ST
Practice Address - Street 2:
Practice Address - City:SAN AUGUSTINE
Practice Address - State:TX
Practice Address - Zip Code:75972-2028
Practice Address - Country:US
Practice Address - Phone:936-275-9910
Practice Address - Fax:936-275-9710
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-08
Last Update Date:2007-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXK1721207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX0084KUOtherBLUE CROSS BLUE SHIELD
TX8K5535OtherBLUE CROSS BLUE SHIELD
TX8B2292Medicare ID - Type UnspecifiedJEFFREY A. WATSON, MD
TX00815VMedicare ID - Type Unspecified
TX0084KUOtherBLUE CROSS BLUE SHIELD