MEDICARE: PEDIAMED NIGHT CLINIC-9740

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	208000000X	Pediatrics Physician

General Provider Information

NPI Number	:	1104197417
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PEDIAMED NIGHT CLINIC-9740

Provider Business Mailing Address
First Line	:	2931 GEORGE DIETER DR
Second Line	:	STE F
City	:	EL PASO
State	:	TX
Zip	:	79936-2941
Country	:	US
Telephone Number	:	915-227-0137
Fax Number	:	915-208-4014

Provider Business Practice Location Address
First Line	:	9740 DYER ST
Second Line	:	STE 111
City	:	EL PASO
State	:	TX
Zip	:	79924-4752
Country	:	US
Telephone Number	:	915-867-4321
Fax Number	:

Authorized Official
Title or Position	:	CEO
Name	:	MR. GUILLERMO ACOSTA
Credential	:
Telephone Number	:	915-227-0137

Provider Enumeration Date	:	01/18/2012
Last Update Date	:	01/18/2012

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