Provider Demographics
NPI:1215042189
Name:CARITAS FAMILY MEDICINE PA
Entity type:Organization
Organization Name:CARITAS FAMILY MEDICINE PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:ALEXANDER
Authorized Official - Last Name:CANNON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:210-650-9066
Mailing Address - Street 1:11901 TOEPPERWEIN RD
Mailing Address - Street 2:SUITE 1201
Mailing Address - City:LIVE OAK
Mailing Address - State:TX
Mailing Address - Zip Code:78233-3161
Mailing Address - Country:US
Mailing Address - Phone:210-650-9066
Mailing Address - Fax:210-650-9067
Practice Address - Street 1:11901 TOEPPERWEIN RD
Practice Address - Street 2:SUITE 1201
Practice Address - City:LIVE OAK
Practice Address - State:TX
Practice Address - Zip Code:78233-3161
Practice Address - Country:US
Practice Address - Phone:210-650-9066
Practice Address - Fax:210-650-9067
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-20
Last Update Date:2017-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXL8002207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX112162601Medicaid
TXP00178727OtherRAILROAD MEDICARE
TX010025319OtherRAILROAD MEDICARE
TX8P1540OtherBLUE CROSS
TX8P1541OtherBLUE CROSS
TX010025319OtherRAILROAD MEDICARE
TX8P1541OtherBLUE CROSS
TXB26839Medicare UPIN
TX8P1540OtherBLUE CROSS