Provider Demographics
NPI:1548446867
Name:WEST TEXAS COSMETIC SURGICAL ASSOC PA
Entity type:Organization
Organization Name:WEST TEXAS COSMETIC SURGICAL ASSOC PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:ELSA
Authorized Official - Middle Name:
Authorized Official - Last Name:JERNIGAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:915-541-1225
Mailing Address - Street 1:1700 N OREGON ST
Mailing Address - Street 2:SUITE 755
Mailing Address - City:EL PASO
Mailing Address - State:TX
Mailing Address - Zip Code:79902-3590
Mailing Address - Country:US
Mailing Address - Phone:915-541-1225
Mailing Address - Fax:915-541-1229
Practice Address - Street 1:1700 N OREGON ST
Practice Address - Street 2:SUITE 755
Practice Address - City:EL PASO
Practice Address - State:TX
Practice Address - Zip Code:79902-3590
Practice Address - Country:US
Practice Address - Phone:915-541-1225
Practice Address - Fax:915-541-1229
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-16
Last Update Date:2008-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXE49592086S0122X
TXL18942086S0122X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2086S0122XAllopathic & Osteopathic PhysiciansSurgeryPlastic and Reconstructive SurgeryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX126386Medicaid
TXB27456Medicare UPIN
TX00322WMedicare PIN
TX126386Medicaid