Provider Demographics
NPI:1225417199
Name:SAN ANTONIO MEDICAL CENTER LLC
Entity Type:Organization
Organization Name:SAN ANTONIO MEDICAL CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:ANTONY
Authorized Official - Middle Name:NGUYEN
Authorized Official - Last Name:VANBANG
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:720-666-5116
Mailing Address - Street 1:1701 S FEDERAL BLVD
Mailing Address - Street 2:UNIT D
Mailing Address - City:DENVER
Mailing Address - State:CO
Mailing Address - Zip Code:80219-4898
Mailing Address - Country:US
Mailing Address - Phone:303-936-1760
Mailing Address - Fax:
Practice Address - Street 1:1701 S FEDERAL BLVD
Practice Address - Street 2:UNIT D
Practice Address - City:DENVER
Practice Address - State:CO
Practice Address - Zip Code:80219-4898
Practice Address - Country:US
Practice Address - Phone:303-936-1760
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-05-26
Last Update Date:2017-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CODR00054747208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO50085034Medicaid
NEE37943Medicare UPIN