Healthcare Provider Details

I. General information

NPI: 1104219781
Provider Name (Legal Business Name): PEDIATRIC INPATIENT CRITICAL CARE SERVICES PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/06/2015
Last Update Date: 08/12/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

520 MADISON OAK DR
SAN ANTONIO TX
78258-3913
US

IV. Provider business mailing address

PO BOX 4346 DEPT 409
HOUSTON TX
77210-4346
US

V. Phone/Fax

Practice location:
  • Phone: 210-297-4000
  • Fax:
Mailing address:
  • Phone: 210-558-6288
  • Fax: 210-558-6289

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080P0203X
TaxonomyPediatric Critical Care Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: HUGO CARVAJAL
Title or Position: PRESIDENT
Credential: MD
Phone: 210-558-6288