Provider Demographics
NPI:1518190859
Name:GENESIS NEUROPSYCHIATRIC CENTER
Entity Type:Organization
Organization Name:GENESIS NEUROPSYCHIATRIC CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:P.A.
Authorized Official - Prefix:DR
Authorized Official - First Name:E.P TED
Authorized Official - Middle Name:
Authorized Official - Last Name:WILLIAMS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:210-404-9696
Mailing Address - Street 1:1380 PANTHEON WAY
Mailing Address - Street 2:#310
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78232-2288
Mailing Address - Country:US
Mailing Address - Phone:210-404-9696
Mailing Address - Fax:210-404-9466
Practice Address - Street 1:1380 PANTHEON WAY
Practice Address - Street 2:#310
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78232-2288
Practice Address - Country:US
Practice Address - Phone:210-404-9696
Practice Address - Fax:210-404-9466
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-09-03
Last Update Date:2009-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXG39122084P0800X, 2084P0804X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Single Specialty
No2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent PsychiatryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX138419010Medicaid