Healthcare Provider Details

I. General information

NPI: 1487696159
Provider Name (Legal Business Name): SAN MARCOS ANESTHESIOLOGY, LLP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/10/2006
Last Update Date: 01/28/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1301 WONDER WORLD DR
SAN MARCOS TX
78666-7533
US

IV. Provider business mailing address

PO BOX 938
KILLEEN TX
76540-0938
US

V. Phone/Fax

Practice location:
  • Phone: 512-753-3627
  • Fax:
Mailing address:
  • Phone: 254-634-6999
  • Fax: 254-200-4090

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number
License Number State

VIII. Authorized Official

Name: DR. CHARLES T PORTER JR.
Title or Position: OWNER
Credential: M.D.
Phone: 512-753-3627