Provider Demographics
NPI:1689841934
Name:SOUTHWEST TEXAS MEDICAL SERVICE
Entity Type:Organization
Organization Name:SOUTHWEST TEXAS MEDICAL SERVICE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ADETOLA
Authorized Official - Middle Name:
Authorized Official - Last Name:TALABI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:832-607-6331
Mailing Address - Street 1:PO BOX 91159
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77291-1159
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4103 LA BRANCH ST
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77004-4822
Practice Address - Country:US
Practice Address - Phone:713-691-7744
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-14
Last Update Date:2008-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXK4261207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX135332810Medicaid
TX00713RMedicare PIN
TX8486N0Medicare PIN