1508813494 NPI number — KELLUM MEDICAL GROUP, PA

Table of content: (NPI 1508813494)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1508813494 NPI number — KELLUM MEDICAL GROUP, PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
KELLUM MEDICAL GROUP, 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:
1508813494
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/16/2025
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
7323 MARBACH RD STE 104
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SAN ANTONIO
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
78227-1905
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
210-674-0257
Provider Business Mailing Address Fax Number:
210-369-9064

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
7323 MARBACH RD STE 104
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SAN ANTONIO
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
78227-1905
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
210-674-0257
Provider Business Practice Location Address Fax Number:
210-369-9064
Provider Enumeration Date:
05/27/2006

Additional Information

Authorized Official

Authorized Official Last Name:
BRAKER
Authorized Official First Name:
KRISTI
Authorized Official Middle Name:
Authorized Official Title or Position:
CREDENTIALING AUTHORIZED OFFICIAL
Authorized Official Telephone Number:
210-674-0257

Provider Taxonomy Codes

  • Taxonomy code: 363A00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363AM0700X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363LF0000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363LP0200X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207Q00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 45D1026258 . This is a "CLIA - KELLUM MEDICAL GROUP, PA - PEDIATRICS" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 1174518625 . This is a "DANIEL H KELLUM SR., DO - NPI" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: CH6982 . This is a "MEDICARE RR GROUP PTAN#" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 1265413264 . This is a "ALICE T. BLACKMON, NP-C / NPI#" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 1588641377 . This is a "SALVADOR VAZQUEZ, MD / NPI#" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 193200000X . This is a "GROUP TAXONOMY" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 1346646510 . This is a "MATTHEW ARISMENDEZ, PA-C / NPI#" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: R-14400 . This is a "RADIOLOGY & X-RAY CERT#" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 00295N . This is a "MEDICARE GROUP PTAN#" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 1063070308 . This is a "MANUELA BERRY, NP-C / NPI#" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 45D0671939 . This is a "CLIA - KELLUM MEDICAL GROUP, PA" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 1366623639 . This is a "KIMBERLY 'KIM' DIAZ, PA-C" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 1508813494 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2025 www.npivalidator.com