Provider Demographics
NPI:1497882245
Name:CCCST - SEGUIN
Entity Type:Organization
Organization Name:CCCST - SEGUIN
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:ROGER
Authorized Official - Middle Name:M
Authorized Official - Last Name:LYONS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:210-595-5300
Mailing Address - Street 1:4411 MEDICAL DR STE 100
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78229-3832
Mailing Address - Country:US
Mailing Address - Phone:210-595-5300
Mailing Address - Fax:210-614-8740
Practice Address - Street 1:1025 N AUSTIN ST
Practice Address - Street 2:
Practice Address - City:SEGUIN
Practice Address - State:TX
Practice Address - Zip Code:78155-4517
Practice Address - Country:US
Practice Address - Phone:830-379-8688
Practice Address - Fax:210-595-5301
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-28
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXE3811207RH0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & OncologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXU406Medicare ID - Type UnspecifiedGROUP