=====================================================
General NPI Number Information
=====================================================
NPI Number | 1083851281
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CICLINTON RHEUMATOLOGY PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/10/2009
-----------------------------------------------------
Last Update Date | 09/26/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 18585 SIGMA RD STE 102
-----------------------------------------------------
City | SAN ANTONIO
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78258-4204
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 210-591-0688
-----------------------------------------------------
Fax | 210-858-0088
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 11844 BANDERA RD # 706
-----------------------------------------------------
City | HELOTES
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78023-4132
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 210-591-0688
-----------------------------------------------------
Fax | 210-858-0088
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MANAGING MEMBER
-----------------------------------------------------
Name | DR. CHELSEA I. CLINTON
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 210-591-0688
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207RR0500X
-----------------------------------------------------
Taxonomy Name | Rheumatology Physician
-----------------------------------------------------
License Number | M8609
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------