=====================================================
General NPI Number Information
=====================================================
NPI Number | 1194890863
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | WALTER M BAIN MD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/21/2006
-----------------------------------------------------
Last Update Date | 06/29/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1303 MCCULLOUGH AVE STE 242
-----------------------------------------------------
City | SAN ANTONIO
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78212-5604
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 210-226-8982
-----------------------------------------------------
Fax | 210-227-1736
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1303 MCCULLOUGH AVE STE 242
-----------------------------------------------------
City | SAN ANTONIO
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78212-5604
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 210-226-8982
-----------------------------------------------------
Fax | 210-227-1736
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Y00000X
-----------------------------------------------------
Taxonomy Name | Otolaryngology Physician
-----------------------------------------------------
License Number | E4184
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------