Provider Demographics
NPI:1285781765
Name:SPORTS MEDICINE ASSOCIATES OF SAN ANTONIO, PA
Entity type:Organization
Organization Name:SPORTS MEDICINE ASSOCIATES OF SAN ANTONIO, PA
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING SPECIALIST
Authorized Official - Prefix:
Authorized Official - First Name:MONICA
Authorized Official - Middle Name:L
Authorized Official - Last Name:MAZONE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:210-340-1479
Mailing Address - Street 1:21 SPURS LANE
Mailing Address - Street 2:STE 300
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78240-1679
Mailing Address - Country:US
Mailing Address - Phone:210-699-8326
Mailing Address - Fax:210-561-7121
Practice Address - Street 1:21 SPURS LANE
Practice Address - Street 2:STE 340
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78240-1680
Practice Address - Country:US
Practice Address - Phone:210-798-8585
Practice Address - Fax:210-798-8580
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SPORTS MEDICINE ASSOCIATES SAN
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-01-05
Last Update Date:2024-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
207XX0005X, 332B00000X
TX207XX0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207XX0005XAllopathic & Osteopathic PhysiciansOrthopaedic SurgerySports MedicineGroup - Multi-Specialty
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX164423902Medicaid