Provider Demographics
NPI:1649346362
Name:PACT-PEDIATRIC ASSOCIATES AT CLOCK TOWER, LLC
Entity type:Organization
Organization Name:PACT-PEDIATRIC ASSOCIATES AT CLOCK TOWER, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PEDIATRICIAN PRACTICE OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DIANE
Authorized Official - Middle Name:A
Authorized Official - Last Name:MCMAINS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:210-494-7758
Mailing Address - Street 1:14811 SAN PEDRO AVE
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78232-3708
Mailing Address - Country:US
Mailing Address - Phone:210-494-7758
Mailing Address - Fax:210-494-2353
Practice Address - Street 1:14811 SAN PEDRO AVE
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78232-3708
Practice Address - Country:US
Practice Address - Phone:210-494-7758
Practice Address - Fax:210-494-2353
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PACT-PEDIATRIC ASSOCIATES AT CLOCK TOWER, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-11-27
Last Update Date:2014-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXE5170208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX092332801Medicaid
TX092332802Medicaid