Provider Demographics
NPI:1225064603
Name:CANCER CARE NETWORK OF SOUTH TEXAS PA
Entity Type:Organization
Organization Name:CANCER CARE NETWORK OF SOUTH TEXAS PA
Other - Org Name:CANCER CARE CENTERS OF SOUTH TEXAS PA
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:H
Authorized Official - Last Name:GORDON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:210-545-6972
Mailing Address - Street 1:100 NE LOOP 410
Mailing Address - Street 2:SUITE # 600
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78216-4700
Mailing Address - Country:US
Mailing Address - Phone:210-242-6541
Mailing Address - Fax:210-212-5136
Practice Address - Street 1:100 NE LOOP 410
Practice Address - Street 2:SUITE # 600
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78216-4700
Practice Address - Country:US
Practice Address - Phone:210-242-6541
Practice Address - Fax:210-212-5136
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-25
Last Update Date:2011-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXE9664207RH0000X, 207RH0003X, 207RX0202X, 207VX0201X, 2085R0001X, 363AM0700X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & OncologyGroup - Multi-Specialty
No207RH0000XAllopathic & Osteopathic PhysiciansInternal MedicineHematologyGroup - Multi-Specialty
No207RX0202XAllopathic & Osteopathic PhysiciansInternal MedicineMedical OncologyGroup - Multi-Specialty
No207VX0201XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecologic OncologyGroup - Multi-Specialty
No2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation OncologyGroup - Multi-Specialty
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedicalGroup - Multi-Specialty
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX00U40QOtherBLUECROSS/BLUESHIELD TX
TX109514302Medicaid
TX109514302Medicaid
TXCI4583.Medicare PIN
TX00U40QMedicare PIN