Provider Demographics
NPI:1093719379
Name:PEDIATRIC EAR, NOSE & THROAT INSTITUTE OF SOUTH TEXAS
Entity Type:Organization
Organization Name:PEDIATRIC EAR, NOSE & THROAT INSTITUTE OF SOUTH TEXAS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:BENJAMIN
Authorized Official - Middle Name:
Authorized Official - Last Name:SALAZAR
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:210-733-4268
Mailing Address - Street 1:PO BOX 29749
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78229-0749
Mailing Address - Country:US
Mailing Address - Phone:210-733-4368
Mailing Address - Fax:210-402-3417
Practice Address - Street 1:16723 HUEBNER RD
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78248-2342
Practice Address - Country:US
Practice Address - Phone:210-733-4368
Practice Address - Fax:210-402-3417
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-06-02
Last Update Date:2011-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX095065103Medicaid
095065101OtherMEDICAID TIP #
095065102OtherCIDC GROUP