Provider Demographics
NPI:1790168417
Name:SAN ANTONIO HEAD & NECK SURGICAL ASSOCIATES
Entity Type:Organization
Organization Name:SAN ANTONIO HEAD & NECK SURGICAL ASSOCIATES
Other - Org Name:EAR, NOSE & THROAT CLINICS OF SAN ANTONIO
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CREDENTIALER
Authorized Official - Prefix:
Authorized Official - First Name:TRACY
Authorized Official - Middle Name:
Authorized Official - Last Name:GIBSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:210-616-0283
Mailing Address - Street 1:926 BOOKLYN AVE
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78215-1637
Mailing Address - Country:US
Mailing Address - Phone:210-616-0283
Mailing Address - Fax:210-616-0071
Practice Address - Street 1:926 BOOKLYN AVE
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78215-1637
Practice Address - Country:US
Practice Address - Phone:210-616-0283
Practice Address - Fax:210-616-0071
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-06-30
Last Update Date:2015-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX093833403Medicaid