Provider Demographics
NPI:1215242607
Name:SOUTH TEXAS ORTHOPAEDIC & SPORTS MEDICINE, PA
Entity type:Organization
Organization Name:SOUTH TEXAS ORTHOPAEDIC & SPORTS MEDICINE, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:FREDERICK
Authorized Official - Middle Name:RYAN WADE
Authorized Official - Last Name:KRAUSE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:830-393-0235
Mailing Address - Street 1:495 10TH ST
Mailing Address - Street 2:SUITE 104
Mailing Address - City:FLORESVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:78114-3162
Mailing Address - Country:US
Mailing Address - Phone:830-393-0235
Mailing Address - Fax:830-393-0413
Practice Address - Street 1:495 10TH ST
Practice Address - Street 2:SUITE 104
Practice Address - City:FLORESVILLE
Practice Address - State:TX
Practice Address - Zip Code:78114-3162
Practice Address - Country:US
Practice Address - Phone:830-393-0235
Practice Address - Fax:830-393-0413
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-08-10
Last Update Date:2010-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXN5791207X00000X, 207XX0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Single Specialty
No207XX0005XAllopathic & Osteopathic PhysiciansOrthopaedic SurgerySports MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXPENDINGOtherBC/BS
TXPENDINGMedicaid
TXPENDINGMedicare PIN