=====================================================
General NPI Number Information
=====================================================
NPI Number | 1750702221
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | TAMARA J MERCHANT-MCCAMBRY MD PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/30/2013
-----------------------------------------------------
Last Update Date | 12/30/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 621 CAMDEN ST
-----------------------------------------------------
City | SAN ANTONIO
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78215-1612
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 210-276-0829
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 621 CAMDEN ST
-----------------------------------------------------
City | SAN ANTONIO
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78215-1612
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 210-276-0829
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PHYSICIAN/OWNER
-----------------------------------------------------
Name | MRS. TAMARA J MERCHANT-MCCAMBRY
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 210-276-0829
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208C00000X
-----------------------------------------------------
Taxonomy Name | Colon & Rectal Surgery Physician
-----------------------------------------------------
License Number | M3019
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------