Provider Demographics
NPI:1710095302
Name:CANCER CARE NETWORK OF SOUTH TEXAS PA
Entity Type:Organization
Organization Name:CANCER CARE NETWORK OF SOUTH TEXAS PA
Other - Org Name:FREDERICKSBURG-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:210-545-6972
Mailing Address - Street 1:100 NE LOOP 410
Mailing Address - Street 2:SUITE 600
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78216-4700
Mailing Address - Country:US
Mailing Address - Phone:210-242-6541
Mailing Address - Fax:210-212-5136
Practice Address - Street 1:204 W SCHUBERT ST
Practice Address - Street 2:
Practice Address - City:FREDERICKSBURG
Practice Address - State:TX
Practice Address - Zip Code:78624-3847
Practice Address - Country:US
Practice Address - Phone:210-242-6541
Practice Address - Fax:210-212-5136
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-25
Last Update Date:2011-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & OncologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX00U40QOtherBLUECROSS/BLUESHIELD TX
TX109514302Medicaid
TX00U40QOtherBLUECROSS/BLUESHIELD TX
TX00U40QMedicare ID - Type Unspecified
TX109514302Medicaid