MEDICARE: ST MARIE CLINIC 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	261QR0400X	Rehabilitation Clinic/Center

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	676630	OTHER	TX	MEDICARE PROVIDER #

General Provider Information

NPI Number	:	1528071123
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ST MARIE CLINIC PA

Provider Business Mailing Address
First Line	:	305 E EXPRESSWAY 83
Second Line	:
City	:	MISSION
State	:	TX
Zip	:	78572-5560
Country	:	US
Telephone Number	:	956-585-7401
Fax Number	:	956-580-1788

Provider Business Practice Location Address
First Line	:	10900 N 103RD ST
Second Line	:
City	:	MISSION
State	:	TX
Zip	:	78573-0979
Country	:	US
Telephone Number	:	956-583-7744
Fax Number	:	956-583-7747

Authorized Official
Title or Position	:	OWNER/CEO
Name	:	DR. EDUARDO CARRLLO
Credential	:	MD
Telephone Number	:	956-583-7744

Provider Enumeration Date	:	08/14/2006
Last Update Date	:	01/16/2009

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Directions to “ST MARIE CLINIC PA ” Practice Location

Language	Start Address	Practice Location

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