Provider Demographics
NPI:1013098607
Name:EL PASO COLON AND RECTAL CLINIC PA
Entity Type:Organization
Organization Name:EL PASO COLON AND RECTAL CLINIC PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MISS
Authorized Official - First Name:CHRISTINE
Authorized Official - Middle Name:
Authorized Official - Last Name:GOMEZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:915-544-4042
Mailing Address - Street 1:4849 N MESA ST STE 201
Mailing Address - Street 2:
Mailing Address - City:EL PASO
Mailing Address - State:TX
Mailing Address - Zip Code:79912-5919
Mailing Address - Country:US
Mailing Address - Phone:915-351-6600
Mailing Address - Fax:915-351-6601
Practice Address - Street 1:900 CHELSEA ST
Practice Address - Street 2:
Practice Address - City:EL PASO
Practice Address - State:TX
Practice Address - Zip Code:79903-4927
Practice Address - Country:US
Practice Address - Phone:915-544-4042
Practice Address - Fax:915-857-7809
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-18
Last Update Date:2018-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXH9957208600000X, 208C00000X
TXN6538208600000X, 208C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Multi-Specialty
No208C00000XAllopathic & Osteopathic PhysiciansColon & Rectal SurgeryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX84633301Medicaid
TX00R19WMedicare PIN
TX84633301Medicaid