Provider Demographics
NPI:1508814385
Name:EMERGENCY PEDIATRIC PHYSICIAN MGMT LLC
Entity Type:Organization
Organization Name:EMERGENCY PEDIATRIC PHYSICIAN MGMT LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:GENERAL PARTNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:S
Authorized Official - Last Name:POTYKA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:210-495-9860
Mailing Address - Street 1:8401 DATAPOINT DR
Mailing Address - Street 2:SUITE 500
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78229-5907
Mailing Address - Country:US
Mailing Address - Phone:210-614-0180
Mailing Address - Fax:210-566-2063
Practice Address - Street 1:520 MADISON OAK
Practice Address - Street 2:PEDS - EMERGENCY ROOM
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78258-3913
Practice Address - Country:US
Practice Address - Phone:210-297-4050
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-04
Last Update Date:2008-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207PP0204XAllopathic & Osteopathic PhysiciansEmergency MedicinePediatric Emergency MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX174511901Medicaid
TX0030MSOtherBCBSTX
TX174511901Medicaid