Provider Demographics
NPI:1720233687
Name:SOUTH PADRE ISLAND PEDIATRIC CENTER
Entity Type:Organization
Organization Name:SOUTH PADRE ISLAND PEDIATRIC CENTER
Other - Org Name:SINTON PEDIATRIC CENTER
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:SANDY
Authorized Official - Middle Name:
Authorized Official - Last Name:GONZALEZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:361-225-1055
Mailing Address - Street 1:301 S SAN PATRICIO ST
Mailing Address - Street 2:
Mailing Address - City:SINTON
Mailing Address - State:TX
Mailing Address - Zip Code:78387-2432
Mailing Address - Country:US
Mailing Address - Phone:361-364-3355
Mailing Address - Fax:361-851-5193
Practice Address - Street 1:301 S SAN PATRICIO ST
Practice Address - Street 2:
Practice Address - City:SINTON
Practice Address - State:TX
Practice Address - Zip Code:78387-2432
Practice Address - Country:US
Practice Address - Phone:361-364-3355
Practice Address - Fax:361-851-5193
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-11-19
Last Update Date:2008-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXE4618261QR1300X
TXG6791261QR1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX127051407Medicaid
TX121157503Medicaid