Provider Demographics
NPI:1124076674
Name:PEDERNALES MEDICAL GROUP LLP
Entity type:Organization
Organization Name:PEDERNALES MEDICAL GROUP LLP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:DANIEL
Authorized Official - Middle Name:R
Authorized Official - Last Name:THOMPSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:830-997-2191
Mailing Address - Street 1:205 W WINDCREST ST
Mailing Address - Street 2:SUITE 310
Mailing Address - City:FREDERICKSBURG
Mailing Address - State:TX
Mailing Address - Zip Code:78624-4479
Mailing Address - Country:US
Mailing Address - Phone:830-997-2191
Mailing Address - Fax:830-997-8202
Practice Address - Street 1:205 W WINDCREST ST
Practice Address - Street 2:SUITE 310
Practice Address - City:FREDERICKSBURG
Practice Address - State:TX
Practice Address - Zip Code:78624-4479
Practice Address - Country:US
Practice Address - Phone:830-997-2191
Practice Address - Fax:830-997-8202
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-05
Last Update Date:2015-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX080710903Medicaid
TX0050AKMedicare ID - Type Unspecified
0050AKMedicare UPIN