Provider Demographics
NPI:1962583930
Name:TRACY L SCHILLERSTROM M.D., P.A.
Entity type:Organization
Organization Name:TRACY L SCHILLERSTROM M.D., P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:TRACY
Authorized Official - Middle Name:LYNN
Authorized Official - Last Name:SCHILLERSTROM
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:210-680-5543
Mailing Address - Street 1:7222 TIMBERLEAF ST
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78238-1350
Mailing Address - Country:US
Mailing Address - Phone:210-680-5543
Mailing Address - Fax:210-641-1816
Practice Address - Street 1:9150 HUEBNER RD STE 255
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78240-1545
Practice Address - Country:US
Practice Address - Phone:210-641-1800
Practice Address - Fax:210-641-1816
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-18
Last Update Date:2007-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXM3083251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXM3083OtherTX MEDICAL LICENSE #