Provider Demographics
NPI:1083118111
Name:CIBOLO CREEK DERMATOLOGY GROUP
Entity Type:Organization
Organization Name:CIBOLO CREEK DERMATOLOGY GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLING
Authorized Official - Prefix:MS
Authorized Official - First Name:MARY
Authorized Official - Middle Name:
Authorized Official - Last Name:ADAIR
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:830-214-7960
Mailing Address - Street 1:PO BOX 2156
Mailing Address - Street 2:
Mailing Address - City:BOERNE
Mailing Address - State:TX
Mailing Address - Zip Code:78006-3602
Mailing Address - Country:US
Mailing Address - Phone:830-971-9151
Mailing Address - Fax:830-331-2475
Practice Address - Street 1:120 DIETERT AVE BLDG STE 300
Practice Address - Street 2:
Practice Address - City:BOERNE
Practice Address - State:TX
Practice Address - Zip Code:78006-2406
Practice Address - Country:US
Practice Address - Phone:830-971-9151
Practice Address - Fax:830-331-2475
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-03-22
Last Update Date:2020-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXJ9523207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty