Provider Demographics
NPI:1942409198
Name:PROVIDENCE MEDICAL AND GERIATRIC ASSOCIATES, PA
Entity Type:Organization
Organization Name:PROVIDENCE MEDICAL AND GERIATRIC ASSOCIATES, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:OLGA
Authorized Official - Middle Name:MARIA
Authorized Official - Last Name:OLIVARES-HERRERA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:956-971-8800
Mailing Address - Street 1:PO BOX 306
Mailing Address - Street 2:
Mailing Address - City:MCALLEN
Mailing Address - State:TX
Mailing Address - Zip Code:78505-0306
Mailing Address - Country:US
Mailing Address - Phone:956-971-8800
Mailing Address - Fax:956-971-8804
Practice Address - Street 1:110 E SAVANNAH AVE
Practice Address - Street 2:BLDG C SUITE 103
Practice Address - City:MCALLEN
Practice Address - State:TX
Practice Address - Zip Code:78503-1241
Practice Address - Country:US
Practice Address - Phone:956-971-8800
Practice Address - Fax:956-971-8804
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-17
Last Update Date:2020-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXM2431208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX0022NPOtherBCBS
TX180576401Medicaid
TX00W422Medicare PIN
TX0022NPOtherBCBS