Provider Demographics
NPI:1427183987
Name:SOUTH TEXAS MEDICAL CENTER
Entity Type:Organization
Organization Name:SOUTH TEXAS MEDICAL CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:JILL
Authorized Official - Middle Name:
Authorized Official - Last Name:WAGGONER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:214-374-2880
Mailing Address - Street 1:2506 S LANCASTER RD
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75216-2532
Mailing Address - Country:US
Mailing Address - Phone:214-374-2880
Mailing Address - Fax:214-374-2853
Practice Address - Street 1:2506 S LANCASTER RD
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75216-2532
Practice Address - Country:US
Practice Address - Phone:214-374-2880
Practice Address - Fax:214-374-2853
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-23
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXJ4593173000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes173000000XOther Service ProvidersLegal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXF69600Medicare UPIN
TX00076SMedicare ID - Type Unspecified