MEDICARE: NORTHEAST BAPTIST SURGERY CENTER LLC

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	261QA1903X	Ambulatory Surgical Clinic/Center	000369	TX

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	490003869	OTHER	TX	RAILROAD MEDICARE

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1407853740
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	NORTHEAST BAPTIST SURGERY CENTER LLC

Provider Business Mailing Address
First Line	:	8715 VILLAGE DR
Second Line	:	SUITE 200
City	:	SAN ANTONIO
State	:	TX
Zip	:	78217
Country	:	US
Telephone Number	:	210-477-1775
Fax Number	:	210-477-1794

Provider Business Practice Location Address
First Line	:	8715 VILLAGE DR
Second Line	:	SUITE 200
City	:	SAN ANTONIO
State	:	TX
Zip	:	78217
Country	:	US
Telephone Number	:	210-477-1775
Fax Number	:	210-477-1794

Authorized Official
Title or Position	:	ADMINISTRATOR
Name	:	MISS MISTY DIANE WALTON
Credential	:
Telephone Number	:	210-477-1788

Provider Enumeration Date	:	07/01/2005
Last Update Date	:	11/05/2009

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