Provider Demographics
NPI:1972842664
Name:MCCI OF TEXAS PRIMARY CARE GROUP PLLC
Entity Type:Organization
Organization Name:MCCI OF TEXAS PRIMARY CARE GROUP PLLC
Other - Org Name:CONVIVA CARE CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VP
Authorized Official - Prefix:
Authorized Official - First Name:GEMMA
Authorized Official - Middle Name:
Authorized Official - Last Name:ROSELLO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:305-500-2000
Mailing Address - Street 1:6101 BLUE LAGOON DR STE 400
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33126-2051
Mailing Address - Country:US
Mailing Address - Phone:305-500-2000
Mailing Address - Fax:
Practice Address - Street 1:18414 US HIGHWAY 281 N STE 104
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78259
Practice Address - Country:US
Practice Address - Phone:210-495-0222
Practice Address - Fax:210-495-5914
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MCCI OF TEXAS PRIMARY CARE GROUP PLLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2013-01-31
Last Update Date:2020-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL291718Medicare PIN