=====================================================
General NPI Number Information
=====================================================
NPI Number | 1144258179
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | LAREDO REGIONAL MEDICAL CENTER
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/29/2006
-----------------------------------------------------
Last Update Date | 11/07/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 10700 MCPHERSON AVE
-----------------------------------------------------
City | LAREDO
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78045-6268
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 956-523-2619
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 7917 MCPHERSON RD SUITE 205, PMB # 233
-----------------------------------------------------
City | LAREDO
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78045-2811
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 956-523-2619
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CFO
-----------------------------------------------------
Name | MR. ELADIO MONTALVO
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 956-523-2086
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207L00000X
-----------------------------------------------------
Taxonomy Name | Anesthesiology Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 367500000X
-----------------------------------------------------
Taxonomy Name | Certified Registered Nurse Anesthetist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------