MEDICARE: CITY OF CONVERSE

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	3416L0300X	Land Ambulance	015002	TX

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	590007189	OTHER	TX	RAIL ROAD MEDICARE

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1063410850
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CITY OF CONVERSE

Provider Business Mailing Address
First Line	:	107 STATION ST
Second Line	:
City	:	CONVERSE
State	:	TX
Zip	:	78109-1433
Country	:	US
Telephone Number	:	210-658-8900
Fax Number	:	210-658-2222

Provider Business Practice Location Address
First Line	:	107 STATION ST
Second Line	:
City	:	CONVERSE
State	:	TX
Zip	:	78109-1433
Country	:	US
Telephone Number	:	210-658-8900
Fax Number	:	210-658-2222

Authorized Official
Title or Position	:	FIRE CHIEF
Name	:	MR. RICHARD WENDT JR.
Credential	:
Telephone Number	:	210-658-8900

Provider Enumeration Date	:	07/14/2005
Last Update Date	:	02/19/2010

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1912948365 — CRISTY ANN MAYHEW LPC
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Directions to “CITY OF CONVERSE ” Practice Location

Language	Start Address	Practice Location

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