Provider Demographics
NPI:1568658227
Name:CHILDREN'S PHYSICIAN SERVICES OF SOUTH TEXAS
Entity Type:Organization
Organization Name:CHILDREN'S PHYSICIAN SERVICES OF SOUTH TEXAS
Other - Org Name:PLASTIC RECONSTRUCTIVE SURGICAL SERVICES OF SOUTH TEXAS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:DALE
Authorized Official - Middle Name:
Authorized Official - Last Name:OBERMUELLER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:361-694-5081
Mailing Address - Street 1:PO BOX 9336
Mailing Address - Street 2:
Mailing Address - City:CORPUS CHRISTI
Mailing Address - State:TX
Mailing Address - Zip Code:78469-9336
Mailing Address - Country:US
Mailing Address - Phone:361-694-1603
Mailing Address - Fax:361-694-6544
Practice Address - Street 1:3533 S ALAMEDA ST
Practice Address - Street 2:
Practice Address - City:CORPUS CHRISTI
Practice Address - State:TX
Practice Address - Zip Code:78411-1721
Practice Address - Country:US
Practice Address - Phone:361-694-4444
Practice Address - Fax:361-694-4445
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CHILDREN'S PHYSICIAN SERVICES OF SOUTH TEXAS
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-09-17
Last Update Date:2023-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic SurgeryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX163786003Medicaid
TX00836VMedicare PIN