Provider Demographics
NPI:1629382817
Name:STOP SA, LLC
Entity Type:Organization
Organization Name:STOP SA, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROGRAM SPONSOR
Authorized Official - Prefix:
Authorized Official - First Name:BERTRAM
Authorized Official - Middle Name:W
Authorized Official - Last Name:ROBERTS
Authorized Official - Suffix:
Authorized Official - Credentials:MD,MPH, DRPH, MHA,
Authorized Official - Phone:210-736-4405
Mailing Address - Street 1:3780 N.W. LOOP 410
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78229
Mailing Address - Country:US
Mailing Address - Phone:210-736-4405
Mailing Address - Fax:210-736-4407
Practice Address - Street 1:3780 N.W. LOOP 410
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78229
Practice Address - Country:US
Practice Address - Phone:210-736-4405
Practice Address - Fax:210-736-4407
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-07-30
Last Update Date:2010-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXE8143207RN0300X
TXK51782084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrologyGroup - Single Specialty
No2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX131802409Medicaid
TX8L12268Medicare PIN
TX131802409Medicaid