Provider Demographics
NPI:1528107240
Name:CC DOCTORS CENTER SOUTH PA
Entity type:Organization
Organization Name:CC DOCTORS CENTER SOUTH PA
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:KEITH
Authorized Official - Last Name:ROSE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:361-992-0227
Mailing Address - Street 1:5536 SARATOGA BLVD
Mailing Address - Street 2:
Mailing Address - City:CORPUS CHRISTI
Mailing Address - State:TX
Mailing Address - Zip Code:78413-2944
Mailing Address - Country:US
Mailing Address - Phone:361-992-0227
Mailing Address - Fax:361-992-0669
Practice Address - Street 1:5536 SARATOGA BLVD
Practice Address - Street 2:
Practice Address - City:CORPUS CHRISTI
Practice Address - State:TX
Practice Address - Zip Code:78413-2944
Practice Address - Country:US
Practice Address - Phone:361-992-0227
Practice Address - Fax:361-992-0669
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-06
Last Update Date:2022-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Single Specialty
No207P00000XAllopathic & Osteopathic PhysiciansEmergency MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXF97486Medicare UPIN