MEDICARE: CANCER CARE NETWORK OF SOUTH TEXAS PA

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	207RH0000X	Hematology (Internal Medicine) Physician	E9664	TX
2	207RX0202X	Medical Oncology Physician	E9664	TX
3	207VX0201X	Gynecologic Oncology Physician	E9664	TX
4	2085R0001X	Radiation Oncology Physician	E9664	TX
5	363AM0700X	Medical Physician Assistant	E9664	TX
6	363L00000X	Nurse Practitioner	E9664	TX
7	207RH0003X	Hematology & Oncology Physician	E9664	TX

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	00U40Q	OTHER	TX	BLUECROSS/BLUESHIELD TX
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1225064603
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CANCER CARE NETWORK OF SOUTH TEXAS PA

Provider Business Mailing Address
First Line	:	100 NE LOOP 410
Second Line	:	SUITE # 600
City	:	SAN ANTONIO
State	:	TX
Zip	:	78216-4700
Country	:	US
Telephone Number	:	210-242-6541
Fax Number	:	210-212-5136

Provider Business Practice Location Address
First Line	:	100 NE LOOP 410
Second Line	:	SUITE # 600
City	:	SAN ANTONIO
State	:	TX
Zip	:	78216-4700
Country	:	US
Telephone Number	:	210-242-6541
Fax Number	:	210-212-5136

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DAVID H. GORDON
Credential	:	MD
Telephone Number	:	210-545-6972

Provider Enumeration Date	:	06/25/2006
Last Update Date	:	11/03/2011

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Directions to “CANCER CARE NETWORK OF SOUTH TEXAS PA ” Practice Location

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