Healthcare Provider Details

I. General information

NPI: 1982979605
Provider Name (Legal Business Name): METHODIST MEDICAL GROUP, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/13/2012
Last Update Date: 03/14/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8109 FREDERICKSBURG RD PHYSICIAN PRACTICE SERVICES
SAN ANTONIO TX
78229-3311
US

IV. Provider business mailing address

8109 FREDERICKSBURG RD PHYSICIAN PRACTICE SERVICES
SAN ANTONIO TX
78229-3311
US

V. Phone/Fax

Practice location:
  • Phone: 210-575-0254
  • Fax: 210-575-0167
Mailing address:
  • Phone: 210-575-0254
  • Fax: 210-575-0167

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 Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code207RC0001X
TaxonomyClinical Cardiac Electrophysiology Physician
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code207RI0011X
TaxonomyInterventional Cardiology Physician
License Number
License Number State

VIII. Authorized Official

Name: MRS. ROBERTA S CLOUD
Title or Position: VICE PRESIDENT
Credential:
Phone: 210-575-8505