Provider Demographics
NPI:1346652575
Name:CHRISTUS PEDIATRIC PHYSICIAN GROUP
Entity Type:Organization
Organization Name:CHRISTUS PEDIATRIC PHYSICIAN GROUP
Other - Org Name:CHILDREN'S HOSPITAL OF SAN ANTONIO PHYSICIAN GROUP
Other - Org Type:Doing Business As
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:CLINTON
Authorized Official - Middle Name:
Authorized Official - Last Name:KOTAL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:210-704-8706
Mailing Address - Street 1:100 NE LOOP 410
Mailing Address - Street 2:SUITE 800
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78216-4700
Mailing Address - Country:US
Mailing Address - Phone:210-704-8706
Mailing Address - Fax:210-704-4695
Practice Address - Street 1:100 NE LOOP 410
Practice Address - Street 2:SUITE 800
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78216
Practice Address - Country:US
Practice Address - Phone:210-704-8706
Practice Address - Fax:210-704-4695
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-05-22
Last Update Date:2022-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
No207VX0000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyObstetricsGroup - Multi-Specialty