Provider Demographics
NPI:1801938121
Name:ADVANCED OBGYN CARE OF SOUTH TEXAS
Entity type:Organization
Organization Name:ADVANCED OBGYN CARE OF SOUTH TEXAS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:EDWARD
Authorized Official - Middle Name:B
Authorized Official - Last Name:BLACKMAN
Authorized Official - Suffix:JR
Authorized Official - Credentials:MD
Authorized Official - Phone:830-769-3970
Mailing Address - Street 1:1901 HWY 97 E
Mailing Address - Street 2:STE 230
Mailing Address - City:JOURDANTON
Mailing Address - State:TX
Mailing Address - Zip Code:78026
Mailing Address - Country:US
Mailing Address - Phone:830-769-3970
Mailing Address - Fax:830-769-3978
Practice Address - Street 1:1901 HWY 97 E
Practice Address - Street 2:STE 230
Practice Address - City:JOURDANTON
Practice Address - State:TX
Practice Address - Zip Code:78026
Practice Address - Country:US
Practice Address - Phone:830-769-3970
Practice Address - Fax:830-769-3978
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-13
Last Update Date:2008-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXM0326207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8D1909OtherMEDICARE
TX8D1909OtherMEDICARE
TX8D1909Medicare Oscar/Certification