Provider Demographics
NPI:1013113463
Name:SAGE FAMILY MEDICINE, PA
Entity Type:Organization
Organization Name:SAGE FAMILY MEDICINE, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ROGER
Authorized Official - Middle Name:
Authorized Official - Last Name:GILDERSLEEVE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:512-244-0446
Mailing Address - Street 1:1000 HESTERS CROSSING
Mailing Address - Street 2:200
Mailing Address - City:ROUND ROCK
Mailing Address - State:TX
Mailing Address - Zip Code:78681
Mailing Address - Country:US
Mailing Address - Phone:512-244-0446
Mailing Address - Fax:
Practice Address - Street 1:1000 HESTERS CROSSING
Practice Address - Street 2:200
Practice Address - City:ROUND ROCK
Practice Address - State:TX
Practice Address - Zip Code:78681
Practice Address - Country:US
Practice Address - Phone:512-244-0446
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-22
Last Update Date:2008-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXM6632207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX00Y218Medicare PIN