Provider Demographics
NPI:1053490631
Name:GASTROENTEROLOGY CLINIC OF SAN ANTONIO, P.A.
Entity Type:Organization
Organization Name:GASTROENTEROLOGY CLINIC OF SAN ANTONIO, P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:RUSSELL
Authorized Official - Middle Name:
Authorized Official - Last Name:HAVRANEK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:210-615-8308
Mailing Address - Street 1:8550 DATAPOINT DR
Mailing Address - Street 2:SUITE 200
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78229-3270
Mailing Address - Country:US
Mailing Address - Phone:210-615-8308
Mailing Address - Fax:210-615-8313
Practice Address - Street 1:8550 DATAPOINT DR
Practice Address - Street 2:SUITE 200
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78229-3270
Practice Address - Country:US
Practice Address - Phone:210-615-8308
Practice Address - Fax:210-615-8313
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-03
Last Update Date:2015-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX044080201Medicaid
TX00BL45OtherMEDICARE PTAN