Provider Demographics
NPI:1649251752
Name:INDEPENDENT MEDICAL ASSOCIATES, P.A.
Entity type:Organization
Organization Name:INDEPENDENT MEDICAL ASSOCIATES, P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MGR
Authorized Official - Prefix:MRS
Authorized Official - First Name:TINA
Authorized Official - Middle Name:V
Authorized Official - Last Name:GOMEZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:210-614-3335
Mailing Address - Street 1:2829 BABCOCK RD
Mailing Address - Street 2:SUITE 110
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78229-6028
Mailing Address - Country:US
Mailing Address - Phone:210-614-5855
Mailing Address - Fax:210-614-6240
Practice Address - Street 1:2829 BABCOCK RD
Practice Address - Street 2:SUITE 110
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78229-6028
Practice Address - Country:US
Practice Address - Phone:210-614-5855
Practice Address - Fax:210-614-6240
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-11-07
Last Update Date:2009-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXE5204207RP1001X
TXF8582207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary DiseaseGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX00U59QOtherTX BC/BS GRP#
TX085706201Medicaid
TX085706201Medicaid
TX=========OtherTXIDN GRP#