Provider Demographics
NPI:1396764577
Name:ST MARIE CLINIC P A
Entity type:Organization
Organization Name:ST MARIE CLINIC P A
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:EDUARDO
Authorized Official - Middle Name:
Authorized Official - Last Name:CARRILLO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:956-585-7401
Mailing Address - Street 1:305 E EXPRESSWAY 83
Mailing Address - Street 2:
Mailing Address - City:MISSION
Mailing Address - State:TX
Mailing Address - Zip Code:78572-5560
Mailing Address - Country:US
Mailing Address - Phone:956-585-7401
Mailing Address - Fax:956-583-5833
Practice Address - Street 1:305 E EXPRESSWAY 83
Practice Address - Street 2:
Practice Address - City:MISSION
Practice Address - State:TX
Practice Address - Zip Code:78572-5560
Practice Address - Country:US
Practice Address - Phone:956-585-7401
Practice Address - Fax:956-583-5833
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-19
Last Update Date:2009-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX168788102Medicaid
TX00669XMedicare Oscar/Certification