Provider Demographics
NPI:1306179171
Name:BAY AREA TOTAL HEALTH MEDICAL GRP, PA
Entity Type:Organization
Organization Name:BAY AREA TOTAL HEALTH MEDICAL GRP, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING ADMIN
Authorized Official - Prefix:MS
Authorized Official - First Name:SANDRA
Authorized Official - Middle Name:A
Authorized Official - Last Name:RODRIGUEZ
Authorized Official - Suffix:
Authorized Official - Credentials:CREDENTIALING ADMIN
Authorized Official - Phone:832-683-4132
Mailing Address - Street 1:333 N TEXAS AVE
Mailing Address - Street 2:STE 4100
Mailing Address - City:WEBSTER
Mailing Address - State:TX
Mailing Address - Zip Code:77598
Mailing Address - Country:US
Mailing Address - Phone:832-984-6549
Mailing Address - Fax:281-338-7755
Practice Address - Street 1:333 N TEXAS AVE
Practice Address - Street 2:STE 4100
Practice Address - City:WEBSTER
Practice Address - State:TX
Practice Address - Zip Code:77598
Practice Address - Country:US
Practice Address - Phone:832-984-6549
Practice Address - Fax:281-338-7755
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-09-11
Last Update Date:2024-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXP8427207Q00000X
TXK5285207R00000X, 261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX0026SVOtherBCBS GRP ID