Provider Demographics
NPI:1285752105
Name:SUMMIT CHILDREN'S CLINIC PA
Entity type:Organization
Organization Name:SUMMIT CHILDREN'S CLINIC PA
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN/OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:SERGIO
Authorized Official - Middle Name:E
Authorized Official - Last Name:RAMON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:210-736-3126
Mailing Address - Street 1:401 W. SUMMIT
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78212
Mailing Address - Country:US
Mailing Address - Phone:210-736-3126
Mailing Address - Fax:210-733-1953
Practice Address - Street 1:401 W. SUMMIT
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78212
Practice Address - Country:US
Practice Address - Phone:210-736-3126
Practice Address - Fax:210-733-1953
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-27
Last Update Date:2011-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXF1687208000000X
TX208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX080323101Medicaid
TX130516101Medicaid
TX041962403Medicaid
TX039825702Medicaid
TX039825702Medicaid
TXG75263Medicare UPIN
TX080323101Medicaid