Provider Demographics
NPI:1467578971
Name:GUSTAVO J MEDELLIN MD PA
Entity Type:Organization
Organization Name:GUSTAVO J MEDELLIN MD PA
Other - Org Name:MEDICAL CENTER HOSPITALISTS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:GUSTAVO
Authorized Official - Middle Name:JAVIER
Authorized Official - Last Name:MEDELLIN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:210-558-6288
Mailing Address - Street 1:PO BOX 1158
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78294-1158
Mailing Address - Country:US
Mailing Address - Phone:210-558-6288
Mailing Address - Fax:210-558-6289
Practice Address - Street 1:7700 FLOYD CURL DR
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78229-3902
Practice Address - Country:US
Practice Address - Phone:210-575-4000
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-22
Last Update Date:2020-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXK0129208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX=========OtherEIN
TX164098901Medicaid
TX00207WMedicare ID - Type UnspecifiedMEDICARE GROUP