Provider Demographics
NPI:1639191836
Name:ST. MARIE CLINIC, P.A.
Entity Type:Organization
Organization Name:ST. MARIE CLINIC, P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:EDUARDO
Authorized Official - Middle Name:
Authorized Official - Last Name:CARRILLO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:956-585-7401
Mailing Address - Street 1:305 E EXPRESSWAY 83
Mailing Address - Street 2:
Mailing Address - City:MISSION
Mailing Address - State:TX
Mailing Address - Zip Code:78572-5560
Mailing Address - Country:US
Mailing Address - Phone:956-585-7401
Mailing Address - Fax:956-583-5833
Practice Address - Street 1:305 E EXPRESSWAY 83
Practice Address - Street 2:
Practice Address - City:MISSION
Practice Address - State:TX
Practice Address - Zip Code:78572-5560
Practice Address - Country:US
Practice Address - Phone:956-583-3775
Practice Address - Fax:956-583-5833
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-24
Last Update Date:2008-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0400XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX168788104Medicaid
TX168788104Medicaid