Healthcare Provider Details

I. General information

NPI: 1144791351
Provider Name (Legal Business Name): CHEZ THERESE MEDICAL CENTER PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/16/2018
Last Update Date: 11/18/2021
Certification Date: 11/18/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6955 N MESA ST STE 101
EL PASO TX
79912-4424
US

IV. Provider business mailing address

4849 N MESA ST STE 201
EL PASO TX
79912-5919
US

V. Phone/Fax

Practice location:
  • Phone: 915-613-3010
  • Fax: 915-201-1253
Mailing address:
  • Phone: 915-351-6600
  • Fax: 915-351-6601

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207RG0300X
TaxonomyGeriatric Medicine (Internal Medicine) Physician
License Number
License Number State

VIII. Authorized Official

Name: AUGUSTINE O BOSAH
Title or Position: PRESIDENT
Credential: MD
Phone: 276-274-2144