Provider Demographics
NPI:1548450190
Name:SOUTH PADRE ISLAND PEDIATRIC CENTER
Entity type:Organization
Organization Name:SOUTH PADRE ISLAND PEDIATRIC CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MULUKUTLA
Authorized Official - Middle Name:
Authorized Official - Last Name:RAMAKRISHNA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:361-854-4626
Mailing Address - Street 1:3845 S SPID DR
Mailing Address - Street 2:
Mailing Address - City:CORPUS CHRISTI
Mailing Address - State:TX
Mailing Address - Zip Code:78415-2919
Mailing Address - Country:US
Mailing Address - Phone:361-854-4626
Mailing Address - Fax:
Practice Address - Street 1:3845 S SPID DR
Practice Address - Street 2:
Practice Address - City:CORPUS CHRISTI
Practice Address - State:TX
Practice Address - Zip Code:78415-2919
Practice Address - Country:US
Practice Address - Phone:361-854-4626
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-30
Last Update Date:2007-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXE4618174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX093832601Medicaid
TX127051404Medicaid
TX645666168Medicaid
TX121157503Medicaid
TX127051405Medicaid
TX645660168Medicaid
TX127051403Medicaid
TX645665166Medicaid
TX092694101Medicaid
TX127051407Medicaid
TX645663163Medicaid
TX127051406Medicaid