MEDICARE: SAINT RAPHAEL FAMILY FOCUSED MEDICINE 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	207Q00000X	Family Medicine Physician	L5014	TX

General Provider Information

NPI Number	:	1447430608
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SAINT RAPHAEL FAMILY FOCUSED MEDICINE PA

Provider Business Mailing Address
First Line	:	10350 BANDERA RD
Second Line	:	SUITE 300
City	:	SAN ANTONIO
State	:	TX
Zip	:	78250-5615
Country	:	US
Telephone Number	:	210-383-6861
Fax Number	:

Provider Business Practice Location Address
First Line	:	10350 BANDERA RD
Second Line	:	SUITE 300
City	:	SAN ANTONIO
State	:	TX
Zip	:	78250-5615
Country	:	US
Telephone Number	:	210-383-6861
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. JAMES MANNING LACKEY
Credential	:	MD
Telephone Number	:	210-383-6861

Provider Enumeration Date	:	11/05/2007
Last Update Date	:	11/05/2007

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