MEDICARE: SOUTH TEXAS CARDIOVASCULAR LABORATORY

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	293D00000X	Physiological Laboratory
2	174400000X	Specialist

General Provider Information

NPI Number	:	1639161763
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SOUTH TEXAS CARDIOVASCULAR LABORATORY

Provider Business Mailing Address
First Line	:	4330 MEDICAL DR
Second Line	:	PAVILION SUITE A
City	:	SAN ANTONIO
State	:	TX
Zip	:	78229-3342
Country	:	US
Telephone Number	:	210-615-7734
Fax Number	:

Provider Business Practice Location Address
First Line	:	4330 MEDICAL DR
Second Line	:	SUITE A
City	:	SAN ANTONIO
State	:	TX
Zip	:	78229-3342
Country	:	US
Telephone Number	:	210-615-7734
Fax Number	:

Authorized Official
Title or Position	:	E D
Name	:	STCL LAB
Credential	:
Telephone Number	:	210-615-7734

Provider Enumeration Date	:	08/16/2005
Last Update Date	:	07/24/2008

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