Provider Demographics
NPI:1558461855
Name:GUADALUPE EAR, NOSE AND THROAT, PA
Entity Type:Organization
Organization Name:GUADALUPE EAR, NOSE AND THROAT, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:GAYE
Authorized Official - Last Name:HENNESSEE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:830-379-0299
Mailing Address - Street 1:PO BOX 1266
Mailing Address - Street 2:
Mailing Address - City:SEGUIN
Mailing Address - State:TX
Mailing Address - Zip Code:78156-1266
Mailing Address - Country:US
Mailing Address - Phone:830-379-0299
Mailing Address - Fax:830-401-0323
Practice Address - Street 1:1414 E WALNUT ST
Practice Address - Street 2:
Practice Address - City:SEGUIN
Practice Address - State:TX
Practice Address - Zip Code:78155-5175
Practice Address - Country:US
Practice Address - Phone:830-379-0299
Practice Address - Fax:830-401-0323
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-25
Last Update Date:2016-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXM1754207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX177183401Medicaid
I42960Medicare UPIN
00551ZMedicare PIN