Provider Demographics
NPI:1912105701
Name:RAYMONDVILLE MEMORIAL HEALTH CENTER PA
Entity Type:Organization
Organization Name:RAYMONDVILLE MEMORIAL HEALTH CENTER PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:GEORGE
Authorized Official - Middle Name:
Authorized Official - Last Name:CANTU
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:956-689-2225
Mailing Address - Street 1:182 E KIMBALL AVE
Mailing Address - Street 2:
Mailing Address - City:RAYMONDVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:78580-2547
Mailing Address - Country:US
Mailing Address - Phone:956-689-2225
Mailing Address - Fax:956-689-3070
Practice Address - Street 1:182 E KIMBALL AVE
Practice Address - Street 2:
Practice Address - City:RAYMONDVILLE
Practice Address - State:TX
Practice Address - Zip Code:78580-2547
Practice Address - Country:US
Practice Address - Phone:956-689-2225
Practice Address - Fax:956-689-3070
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-03
Last Update Date:2012-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXJ5271207RG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX111716001Medicaid
TXTXB124687Medicare PIN