MEDICARE: SOUTH TEXAS SPORTS MEDICINE INC

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	261QP2000X	Physical Therapy Clinic/Center
2	225100000X	Physical Therapist

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	0019BG	OTHER	TX	BLUE CROSS BLUE SHIELD
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
3	177212100	OTHER		DEPARTMENT OF LABOR
4	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1235160250
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SOUTH TEXAS SPORTS MEDICINE INC

Provider Business Mailing Address
First Line	:	5530 LIPES BLVD
Second Line	:
City	:	CORPUS CHRISTI
State	:	TX
Zip	:	78413-5511
Country	:	US
Telephone Number	:	361-993-9494
Fax Number	:	361-993-4477

Provider Business Practice Location Address
First Line	:	203 CEDAR DR
Second Line	:
City	:	PORTLAND
State	:	TX
Zip	:	78374-2900
Country	:	US
Telephone Number	:	361-643-3993
Fax Number	:	361-687-2465

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DONALD R ZYLKS
Credential	:	PH.D
Telephone Number	:	361-728-4288

Provider Enumeration Date	:	07/06/2006
Last Update Date	:	05/22/2025

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Directions to “SOUTH TEXAS SPORTS MEDICINE INC ” Practice Location

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