Provider Demographics
NPI:1629237912
Name:CANCER CARE NETWORK OF SOUTH TEXAS PA
Entity Type:Organization
Organization Name:CANCER CARE NETWORK OF SOUTH TEXAS PA
Other - Org Name:NORTHEAST METHODIST-S.A.TUMOR&BLOOD
Other - Org Type:Other Name
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:H
Authorized Official - Last Name:GORDON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:210-381-6533
Mailing Address - Street 1:12709 TOEPPERWEIN RD
Mailing Address - Street 2:SUITE 306
Mailing Address - City:LIVE OAK
Mailing Address - State:TX
Mailing Address - Zip Code:78233-3258
Mailing Address - Country:US
Mailing Address - Phone:210-381-6533
Mailing Address - Fax:
Practice Address - Street 1:12709 TOEPPERWEIN RD
Practice Address - Street 2:SUITE 306
Practice Address - City:LIVE OAK
Practice Address - State:TX
Practice Address - Zip Code:78233-3258
Practice Address - Country:US
Practice Address - Phone:210-381-6533
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-06-03
Last Update Date:2010-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & OncologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX109514302Medicaid
TX00U40QOtherBLUECROSS/BLUESHIELD TX
TX00U40QMedicare PIN
X05189Medicare UPIN