Dats Summary 1D Last Reattestaion Date: 44/2014 40:16:24 AM ‘CAGH Data Summary as of 12/2015 ALVAREZ, RUDY Medical Dector (MD) ‘CAH Provider ID: 12415184 ag oo Nees comin Pee er reel conte ce os a on wens oo 7 on cai movi on — oe a vastness casita on ea o ~ oo csi vv ou — 7 Crmnmce gas Copowouetae: grea oe Pn inne nanny jehaggiin Pt a aan proce pos ecena —— nna wears a oes ams ‘oun ares on rocoto set arene ae eset borane vn sere is coe teat Gender: Male RacelEthricity HispariccorLatino/aBirth Date anen982 Birth State 1x Citzenship County Unites States Work Permits and Visas ‘Are youeligible towork in Yes the United States ‘Visa Number ies Status : Languages ‘Mon-Enelish languages: “spoken by provider Birth city Birth Country ‘oatten nitee States Pease Mae Ure DI sa rn pay ———c e Expraton Dee secs ea mb we toyoutoren Se we Aegan Cerone? a 7 oe ones toons = toposes ura 7 a USULE Step! Passed USULE Step? Passed Doyou have a Educational Commission for Foreign ‘Medical Gracuates (ECFIG) Number? Doyou have DPS Certiication? he License Type License State Issue Date USMLE Exam Date USMLE Step2 Passed ™ a) EDUCATION ‘Graduate Type ‘usicenase Graauare Professional Schoo! ry Teas esa ‘SuterBuildingt State 1x Postal Code e229 Province: Phone Degree Mecical Degree Type wD Professional School Start 06/2004 Study Major PE ge] Professional School End ‘7703 Floyd Cul Dive ‘San Antonio 0/2008,‘Education completed inthis Completion Date ‘school cartiioate ReceivediAwarded Benn aes Ue Residency: Country: United States State w County Institution Hospital Name Indiana Univesity School of _Afiliated University Indiana Unversity - Purdue Macicine Univesity Indianapolis city Inianapatis Peoinoe: Zip Code e202 Phone: End Date 02012 Type of Residency -snatomic pathology, dinical pathology Department: Pathology and Laboratory Specialty Fathology. Anstomic Mecisine, Pathology & Clirieal Pathology Program Director Care Phillips, MD ‘Current Program Director: yas Hattab, MO Did you compete the Yes Completion Date ce2012 institution? Continuing Edueation Have yeu completed the continuing education hours as required by your State Licensing Board during the past two {2}years OR me required CMEIGEU nours (f applicable) trom the State licensing board is which you are currently practicing? Teainina: I there are any gaps inyour training (greater than 30 days), or ifyouhave not completed any portion of your taining, please explain Svonsorship. Country State county Please name your primary sponsoring physician street! ‘Street city Province. ZipCode Phone: Fax Number SPECIALTY INFORMATION Primary Specially, Doyou have any Yes ‘speciaites Primary specialty Petrology, Anatomic Pathology & Cinical Pattology Mame of Certtying Board ‘American Bostd of Pathology[Cxpiration Date board exam but failed? Doyou wish tobe listed in the directory under this primary specialty? By HMO Doyou wish to be listed in the directory under this primary specially? By PPO. savant Yes Yes Last Recertifiation Datel Do you wish tobe listed in the directory under this primary epeciaty? By POS sayvan22 Yes CERTIFICATION INFORMATION ‘Doyou have Certifications? Other Interests Ne ane ee ses Ng] CredentalingContact: Lasttlame: ‘Midd iia Alvarez PrasticaLocation Firstlame Address city: Zip Code Province Fax Fudy 209 BaylorAve ‘oatten 78504 ALVAREZCountry: Please indicate ifthis is {your primary office location: Mailing Address Mailing Address-streett Mailing Address-city Mailing Address-County Mailing Address-Zip Code Type of Practice ‘tort Date Doss this office qualityas minority business enterprise Group Medicaid Number NPL Type 2 Office Phone Number (Office Fax tlumber Back Office Phone umber Taxi Group tumber Group Name Have you closed your practice to any plans or city Doyou wantio list this site inthe directory address? [After Hours, back office phone number for health plan business use only Mew Patients ? Allnew Patients ? ew payor existing patents ? Mew Medicare patients ? ew Medicaid patients ? ew patients wi referal? Under what circumstances do you socapt rfeeralz? (ie, letter fem another physician, ete Doss this information vary Unites States Yes 12 NOLANA 290 MCALLEN e604 Single Speciaty Goup ‘95¢0202225 ‘9500202276 ‘9500202225 502210020 ‘epee202226 RGV PATHOLOGY ‘CONSULTANTS, PA Yes ‘9500202226 ap voce aus Office E-mail Address: Can general Yes correspondence be sent to this lncation? Mailing Address-Street2 suite 220 Mailing Address-State % Mailing Address-Province Mailing Address-Country United States End Date Group Medicare Number Office Phone Extenton Type of Tax 1D ‘croup Is this the primary Tax IDfor Yes this practice losation? Deselection start date: What questions should we determine the appropriateness of me refercal ItY¥es, please provideby neatm pian” Monday Office Hours, Stert Tine Tuesday Office Hours Stert Tine Wednesday Office Hours Stert Tine Thursday Office Hours, Stert Tine Friday Office Hours Stert Tine ‘Saturday Office Hours, Stert Tine ‘Sunday Office Hours, Stert Tine Doyou have any Yes PartnersiAssociate at this location? Parner: Lastilame cavazas Midae itil ‘Specialty Pathology, Anstomio Pathology & Clinical Patroloay this location Lastilame Showing Midale itil ‘speciaty Patnology, Anatomic Pathology & Cinicel Pathology this location Covering Colleagues, Lastilame Midate Name Specialty Provider Typ Doyou have any midevel No practitioners at this location? Lastilame Midale itil Specialy ‘State License Number Offce Manacer Lastilame Menendez explanation below End Time: End Time: End Time: End Time: End Time: End Time: End Time: Firstllame. Filbert Does this partneriassociate Yes Firstllame. Lisi Does this partneriassociate Yes provide coverage ter you Prowaer ype no Firsttlame. Firsttlame. ‘utc Provider ype License State Firstllame, EnriqueMidae nti Fax Number Is Office Manager CCredentaling Contact Billing Contact Office Manager & Billing Country Electroric billing ‘capabilities ? Offce Manager & Paves Contactare same? Lastilame Midale nti Suite, Department etc. ‘tate: Country: Phone Number Fax Number ‘Are there any Practice Description ‘Age Limitations 2 Minimum Age Limitation Other Limitaton Description: Doss ths office meet ADA accessibility requirements ? Doss this office provide handiaapped acceesibilty 7 Otter Handicapped Aovess: Is this ofce accessible by public wansportaton Resiona Train ‘9500202275 sxpancer@medtolution nat Yes Yes Phone Number: Email Address city Firstllame. ‘Street Address: city Province: Zip Code Email Address Maximum Age Limitation Other Handicapped Access seeen02225 PA,Dots this Location Provide hid Care Services? Dots this office have other ‘services for the disabled ? Test Telephony -TTY ‘American Sign Language - ASL MentaliPhysical Impairment Other Dicabilty Services Mon English tanguage ‘spoken by office personne! Imerpreters Available ? Ityes, specity languages Radiology Services ? Keay? EKG Services ? care of Minor Lacerations ? Pulmonary Function testing ? Allergy injections? Allergy Skin Testing ? Offce Gynecology ? Drawing Blood > Asthma Treatment? ‘Age Appropriate Immunizations ? Flexible Sigmoidoscopy ? Tympanomety/Audiometry Proceduresfincluding ‘surgical? ‘Osteopathic Manipulation 2 IV hyération treatment ? Cardige Stress Test ? Physical therapy ? Is anesthesia administered in your office? Anesthesia Administered by Lastilame & & a 5 REE RRR E ae 5 5 FE omer Transporation Employee Type: Health Core Prouiere Employee type: ‘AcereaitingiCemttying Programe 9, CLIACOLAMLE,AAFP,CAP,ets) X-Ray Certification Type wnatelassicategory ot ‘anesthesia is used ? [Anesthesia Administered by First lame. eee mn ees) Do you have hospital privileges ? PrimareHossital: Yes‘State Address city Phone Number Email Address Department Afliation Start Date Full unrestricted privileges ? ‘Are privileges temporary? ‘omer (speciyy Department birectrs First Name Department Birector’s Last Name Other Hospital ‘State iy Department privileges ? ‘Are privileges temporary? Department Directors First Name ‘omer Hospital Address city Phone Number Department Asfliation Start Date Full unrestricted Are privileges temporary? Department Director's First ™ 301 West Expressway 83 Mettlen ‘9588224000 aan Yes ™ 12202 Comenstone Boulevard Eginburg sseo184e48 aan1a Hospital Name oAllen Medical Censer SuiterBuilding # ZIP Code 7502 Fax Affiliation End Date Admiting Priviege Status: Other Of your total annual 20 percentage is to this hosp? Department Directors Midd Inia No longer affiliated explanation Hospital Name Edinburg Regional Medical ce Of your total annual = admissions, what percentage is to this hospital? Department Directors explanation Hospital name comestone Regions! Hospital ‘SuiterBuilding # ZIP Code 7508 Fax Affiliation End Date Admiting Priviege Status: Other admissions, what percentage is to this hospital? Department Director'sDepartment Director's Last Other Hospital Adiross Phone Number [Asfliation Start Date Full unrestricted privileges 7 ‘Ave privileges temporary? Department Director's First Department Director's Last HospitaPrivieges Hospital aaiross Phone Number ‘Asiiation Start Date Full unrestricted privileges 2 Are privileges temporary? 1900 South D Strest estan ‘9569942000 ana Yes No longer afiited Hospital Name ‘SuiterBuilding # ZIP Code Fax Affiliation End Date ‘Admitting Privilege Status ot your wat annuat ‘admissions, what percentage is to this hospital? Department Director's Midde Inst No longer afiited Hospital Name ‘Suiter@uilsing # AP code Fax [filiation End Date ‘Admitting Privilege Status Of your toial annual ‘admissions, what percentage is t thie hospital? Department Directors No longer amiated oAllen Hear Hospital 78502 other INSURANCE INFORMATION ‘Seftinsured ? city Current Expiration Date “Texas Medical Listility Trust 9015 Mo Packspy Ste £00 Length of fime With country: ‘3 yeanIfyou have changed your ‘coverage within he last ten years, did you purchase tail ‘andlor nose (prior ‘eccurrencelacts} coverage? Individual Coverage 19991000 Yes ‘s599011.0000 Pr Taerenan ec een) (Current Work information Current Employer Practice/Employes Name ‘Street 1 Fax ‘tert Date Previous Work Information Practice/Employer Name ‘Street 1 Fax ‘tert Date Reason for Departure Work History Gap: Doyou have any worke history gaps greater than 3 ‘Are you currently on active ‘military duty Yes GV Pathology Consultants, PA e12W Nolans Ave #220 ctten x o7a011 No Valencia and Sanchez, ND e12W Nolans Ave #220 ctten x o7a012 started oun compary End Date 78504 nitee States 78504 nitee States ovr204 REFERENCES INFORMATION Provider Type First Name Lastilame FilitertoAddress 301 West Expressway 83 City Mostien Postal Code: e608 Province: Email Address Phone ‘9508926052 Tite Physicien. Patholocy Provider Type First Name Lie Lastilame Showing Address 301 Expressway 83 City Meostien Postal Code: e608 Province: Email Address Phone ‘e5e09246252 Tite Phsician, Patoloay Provider Type First Name carlos Lastilame Matiot Address 1900 Sout Bryan Re cit Mission Postal Code: e604 Province: Email Address Phone ‘9562228000 Tite Physician Patholoaist SuiterBuilsingt Country Fax SuiterBuilsingt Country Fax SuiterBuildingt Country Fax ethology Dent Unite States pathology Dept nites States atholoay Dest nites States Pema ee UCT TK Licensure 4. Has your license to practice inyour profession ever been denied, suspended, revoked, restricted, voluntarily No surrendered while under investigation, or have you ever been subject toa consent order, probation or any ‘conditions or imitations by any state licensing board? 2 Have you aver received 2 reprimand or bean fined by any state licansing beard? Me denied, suspended, revoked, restricted, denied renewal or subject o probationary orto other disciplinary cenditions (or reasons other than nor-zompletion of medical records when queliy of care was not adversely affected) or have [preceecings toward any of froze ends been insttutec or recommended by any hospital or healthcare institution, ‘medical staf or commitee, or governing board? 4. Have you voluntarily surrendered, ited your privileges or not reapplied for privileges while under No investication? ‘5. Have you ever been terminated for cause or not renewed for cause from participation, or baen subject to any No disciplinary zction, by any managed care oxganizations (including HMOs, PPOs, or provider erganzations such as tae, PHO=)? 65. tvore you ever placed on probation, dicaiplined, formally reprimanded, sucpended or acked to resign during an ne internstip, residency, fellowship, preceptorship or other clinical education program? Ifyou are current in atraining ‘pregram, nave you been placed en probation, alscipiined, formally reprimanded, suspended or asked to resign?7 Have you ever, while uncer investigation, voUntaly witharawn or prematurely lerminated your status 25 2 studentor employee in any internship, residency, fellowship, preceptorship, ot other clinical education program? 8, Have any of your board certifications oF eligibility ever been revoked? ‘8. Have you ever chosen nct to re-cerify of voluntary surrendered your boaré certficaton(s) while under investigation? DEA or cDS. 410. Have your Federal DEA andlor DPS Controlled Substances Certfcate(s) or authorizations) ever been denied, suspended, revoked, restricted, denied renewal, or voluntarily relinquished? Mediate, Medicaid or other Governmental Prasram Particination - 11 Have you ever been disciplined, excluded from, éebarred, suspended, reprimanded, sanctioned, censured, disqualified or otherwise restricted in regard to participation inthe Medicare or Medicaid program, or in regard to 12 Are you currently ot have you ever bees the subject ofan investigation by any hospital, licensing authority, DEA ‘or DPS authorizing entities, education or training program, Medicare or Medicaid program, or any other private, federal or state health program? 418. To your knowledge, has information pertaining to you ever been reported tothe National Practitoner Data Bank (or Healticare Integrity and Protection Oata Sank? 14. Have you ever received sanctions from or baen the subject of investigation by any regulatory agencies (@-0, CLA, OSHA, eto)? 418, Have you ever bees investigated, sanctioned, reprimanded or cautioned by a military hospital, facility, or agency, or voluntarily arminated or osigned wiile under investigation by = hespital or healtheare facility of any ‘military agency? Malpractice Claims Histony 416. Have you had any malpractice actions within the past 5 years (pending, settled, arbitated, mediated, or liugatea)? It yes, provige intormation fr each case. ‘Criminavciva Histor 17. Have you ever been convicted of, pled guilt to, oF pled nolo contendere t any felony thatis reasonably telated to,our qualifeations, competence, functions, or duties as a medical professional? 418. Have you ever been convicted of, pled guilt to, or pled nolo contendere to any felony including an act of vielence, child abuse or a sexual offense? 49. Have you ever been courtmartialed for actions related to your duties as a medical professional? Ability to Pertorm Job 20. Are you currertly engaged in he ilegal use of drugs? ("Currently" means sufficiently recent to justify 2 ‘easoneble belief thatthe use of drug may have an ongoing impact on one's ability to practice medicine itis not limited to the day of, orwithin a matter of days of weeks before the date of application, rather that thas occurred recently enough to indicate the individual is actively engaged in such conduct “Illegal use of drugs" refers to drugs ‘whose possession or cistribution is unlawiul under the Controled Substances Act, 21 U.S.C. 812.22. Itdoes not Include the use of drug taken under supervision bya licensed healthcare professional, or ether uses authorized by the controlled Substances Actor other provision of Feral law." The term doas include, however, the unlawful use ‘of prescription controlled substances 21. Do you use any chemical substances that would in any way impair or limit your ability to practice medicine and petform the functions of yur jah with roasanabl skill and safety? 22. Do you have any roaconte beliove thatyou would pose 2 rick tothe eafety or wall being of your pationte? 22. fire you tnable to parform the exsential functions of = practtionsr in your araa of practice, with or without rezsonsble accommodation?