=====================================================
General NPI Number Information
=====================================================
NPI Number | 1972570117
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | METHODIST MEDICAL CENTER ASC LP
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/07/2006
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4411 MEDICAL DR
-----------------------------------------------------
City | SAN ANTONIO
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78229-3822
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 210-575-4584
-----------------------------------------------------
Fax | 210-575-4521
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4411 MEDICAL DR
-----------------------------------------------------
City | SAN ANTONIO
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78229-3822
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 210-575-4584
-----------------------------------------------------
Fax | 210-575-4521
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CHIEF FINANCIAL OFFICER
-----------------------------------------------------
Name | MR. TIMOTHY A CARR
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 210-575-0238
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QA1903X
-----------------------------------------------------
Taxonomy Name | Ambulatory Surgical Clinic/Center
-----------------------------------------------------
License Number | 007852
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------