Provider Demographics
NPI:1053684761
Name:GMG HEALTH SYSTEMS, PA
Entity Type:Organization
Organization Name:GMG HEALTH SYSTEMS, PA
Other - Org Name:GONZABA MEDICAL GROUP
Other - Org Type:Doing Business As
Authorized Official - Title/Position:SR CREDENTIALING SPECALIST
Authorized Official - Prefix:MRS
Authorized Official - First Name:GAIL
Authorized Official - Middle Name:
Authorized Official - Last Name:SOUTHARD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:210-921-3867
Mailing Address - Street 1:720 PLEASANTON RD
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78214-1306
Mailing Address - Country:US
Mailing Address - Phone:210-921-3800
Mailing Address - Fax:210-334-2851
Practice Address - Street 1:720 PLEASANTON RD
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78214-1306
Practice Address - Country:US
Practice Address - Phone:210-921-3800
Practice Address - Fax:210-334-2851
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-02-13
Last Update Date:2012-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX664714261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care