=====================================================
General NPI Number Information
=====================================================
NPI Number | 1609124312
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SPORTS MEDICINE ASSOCIATES OF SAN ANTONIO, PA
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/28/2012
-----------------------------------------------------
Last Update Date | 09/30/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5917 BROADWAY ST
-----------------------------------------------------
City | SAN ANTONIO
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78209-5235
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 210-253-3450
-----------------------------------------------------
Fax | 210-477-1037
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 21 SPURS LN STE 300
-----------------------------------------------------
City | SAN ANTONIO
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78240-1679
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 210-699-8326
-----------------------------------------------------
Fax | 210-561-7121
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | ADMINISTRATOR
-----------------------------------------------------
Name | WANDA BATCH
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 210-699-8326
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 332B00000X
-----------------------------------------------------
Taxonomy Name | Durable Medical Equipment & Medical Supplies
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 225100000X
-----------------------------------------------------
Taxonomy Name | Physical Therapist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------