Provider Demographics
NPI:1225106875
Name:CHILDRENS CRITICAL CARE OF SAN ANTONIO PA
Entity Type:Organization
Organization Name:CHILDRENS CRITICAL CARE OF SAN ANTONIO PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:W
Authorized Official - Last Name:MARCUM
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:210-785-8282
Mailing Address - Street 1:5925 KIRBY DR
Mailing Address - Street 2:E354
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77005-2546
Mailing Address - Country:US
Mailing Address - Phone:210-785-8282
Mailing Address - Fax:210-785-8288
Practice Address - Street 1:5925 KIRBY DR
Practice Address - Street 2:E354
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77005-2546
Practice Address - Country:US
Practice Address - Phone:210-785-8282
Practice Address - Fax:210-785-8288
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-01
Last Update Date:2009-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXM30092080P0203X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2080P0203XAllopathic & Osteopathic PhysiciansPediatricsPediatric Critical Care MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX178280701Medicaid
TX0014NHOtherBCBS