Provider Demographics
NPI:1356728455
Name:CARDIOVASCULAR CONSULTANTS CENTRAL TEXAS PLLC
Entity type:Organization
Organization Name:CARDIOVASCULAR CONSULTANTS CENTRAL TEXAS PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SOLE MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:GEORGE
Authorized Official - Middle Name:S
Authorized Official - Last Name:REBECCA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:254-526-9766
Mailing Address - Street 1:4200 W STAN SCHLUETER LOOP BLDG C
Mailing Address - Street 2:
Mailing Address - City:KILLEEN
Mailing Address - State:TX
Mailing Address - Zip Code:76549-5724
Mailing Address - Country:US
Mailing Address - Phone:254-526-9766
Mailing Address - Fax:254-637-7700
Practice Address - Street 1:4200 W STAN SCHLUETER LOOP BLDG C
Practice Address - Street 2:
Practice Address - City:KILLEEN
Practice Address - State:TX
Practice Address - Zip Code:76549-5724
Practice Address - Country:US
Practice Address - Phone:254-526-9766
Practice Address - Fax:254-637-7700
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-04-28
Last Update Date:2016-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXJ3883207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular DiseaseGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX034410301Medicaid
TX034410301Medicaid