MEDICARE: DR. PENDLETON BREWSTER WICKERSHAM M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207RR0500X	Rheumatology Physician	M3113	TX

General Provider Information

NPI Number	:	1053380048
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. PENDLETON BREWSTER WICKERSHAM M.D.

Provider Business Mailing Address
First Line	:	4511 HORIZON HILL BLVD
Second Line	:	SUITE 150
City	:	SAN ANTONIO
State	:	TX
Zip	:	78229-2263
Country	:	US
Telephone Number	:	210-477-2626
Fax Number	:	210-477-2650

Provider Business Practice Location Address
First Line	:	4511 HORIZON HILL BLVD
Second Line	:	SUITE 150
City	:	SAN ANTONIO
State	:	TX
Zip	:	78229-2263
Country	:	US
Telephone Number	:	210-477-2626
Fax Number	:	210-477-2650

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/14/2006
Last Update Date	:	02/01/2015

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