Healthcare Provider Details

I. General information

NPI: 1568280808
Provider Name (Legal Business Name): SPORTS MEDICINE ASSOCIATES OF SAN ANTONIO, PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/26/2024
Last Update Date: 09/30/2024
Certification Date: 09/30/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10622 STATE HIGHWAY 151 STE 205
SAN ANTONIO TX
78251-4729
US

IV. Provider business mailing address

PO BOX 268996 DEPT 1131
OKLAHOMA CITY OK
73126
US

V. Phone/Fax

Practice location:
  • Phone: 210-699-8326
  • Fax: 210-561-7121
Mailing address:
  • Phone: 210-699-8326
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207XX0004X
TaxonomyOrthopaedic Foot and Ankle Surgery Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207XX0005X
TaxonomySports Medicine (Orthopaedic Surgery) Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number
License Number State

VIII. Authorized Official

Name: JULIE BIRKELO
Title or Position: CREDENTIALING SPECIALIST
Credential:
Phone: 210-756-5240