Healthcare Provider Details

I. General information

NPI: 1346652575
Provider Name (Legal Business Name): CHRISTUS PEDIATRIC PHYSICIAN GROUP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/22/2014
Last Update Date: 01/27/2022
Certification Date: 01/27/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 NE LOOP 410 SUITE 800
SAN ANTONIO TX
78216
US

IV. Provider business mailing address

100 NE LOOP 410 SUITE 800
SAN ANTONIO TX
78216-4700
US

V. Phone/Fax

Practice location:
  • Phone: 210-704-8706
  • Fax: 210-704-4695
Mailing address:
  • Phone: 210-704-8706
  • Fax: 210-704-4695

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207VX0000X
TaxonomyObstetrics Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State

VIII. Authorized Official

Name: CLINTON KOTAL
Title or Position: EXECUTIVE DIRECTOR
Credential:
Phone: 210-704-8706