Provider Demographics
NPI:1225283807
Name:SOUTH PADRE ISLAND PEDIATRIC CLINIC
Entity Type:Organization
Organization Name:SOUTH PADRE ISLAND PEDIATRIC CLINIC
Other - Org Name:SOUTH PADRE ISLAND PEDIATRIC CNTR-ARANSAS PASS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:SANDY
Authorized Official - Middle Name:
Authorized Official - Last Name:GONZALEZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:361-854-4626
Mailing Address - Street 1:160 S 13TH ST
Mailing Address - Street 2:
Mailing Address - City:ARANSAS PASS
Mailing Address - State:TX
Mailing Address - Zip Code:78336-4434
Mailing Address - Country:US
Mailing Address - Phone:361-758-1984
Mailing Address - Fax:361-851-5193
Practice Address - Street 1:160 S. 13TH STREET
Practice Address - Street 2:
Practice Address - City:ARANSAS PASS
Practice Address - State:TX
Practice Address - Zip Code:78336
Practice Address - Country:US
Practice Address - Phone:361-758-1984
Practice Address - Fax:361-851-5193
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-11-24
Last Update Date:2008-11-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXG6791261QR1300X
TXE4618261QR1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX127051406Medicaid