1023198637 NPI number — TYLER KIDNEY DOCTORS PA

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1023198637 NPI number — TYLER KIDNEY DOCTORS PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
TYLER KIDNEY DOCTORS PA
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1023198637
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/11/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 132506
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
TYLER
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
75713-2506
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
903-594-2293
Provider Business Mailing Address Fax Number:
903-566-0167

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
700 OLYMPIC PLAZA CIR
Provider Second Line Business Practice Location Address:
912
Provider Business Practice Location Address City Name:
TYLER
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
75701-1951
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
903-594-2293
Provider Business Practice Location Address Fax Number:
903-848-9513
Provider Enumeration Date:
10/17/2006

Additional Information

Authorized Official

Authorized Official Last Name:
DOBROWOLSKI
Authorized Official First Name:
ROBERT
Authorized Official Middle Name:
C
Authorized Official Title or Position:
PHYSICIAN
Authorized Official Telephone Number:
903-594-2293

Provider Taxonomy Codes

  • Taxonomy code: 207RN0300X , with the licence number:  J8518 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 0032NC . This is a "BCBS GROUP" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".




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