Provider Demographics
NPI:1659679157
Name:WELLMED MEDICAL GROUP, P.A.
Entity Type:Organization
Organization Name:WELLMED MEDICAL GROUP, P.A.
Other - Org Name:WELLMED AT TELSHOR
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:CARLOS
Authorized Official - Middle Name:O
Authorized Official - Last Name:HERNANDEZ
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:210-877-7570
Mailing Address - Street 1:8637 FREDERICKSBURG RD STE 360
Mailing Address - Street 2:ATTN: DIRECTOR OF ACCOUNTS RECEIVABLE
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78240-1285
Mailing Address - Country:US
Mailing Address - Phone:210-877-7570
Mailing Address - Fax:210-641-2235
Practice Address - Street 1:530 N TELSHOR BLVD STE C
Practice Address - Street 2:
Practice Address - City:LAS CRUCES
Practice Address - State:NM
Practice Address - Zip Code:88011-8243
Practice Address - Country:US
Practice Address - Phone:575-323-6500
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-03-08
Last Update Date:2019-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
00F34LMedicare PIN