1790094506 NPI number — SAN ANTONIO KIDNEY DISEASE CENTER PHYSICIANS GROUP, P.L.L.C.

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 1790094506 NPI number — SAN ANTONIO KIDNEY DISEASE CENTER PHYSICIANS GROUP, P.L.L.C.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SAN ANTONIO KIDNEY DISEASE CENTER PHYSICIANS GROUP, P.L.L.C.
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:
1790094506
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/09/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
7142 SAN PEDRO AVE
Provider Second Line Business Mailing Address:
SUITE 120
Provider Business Mailing Address City Name:
SAN ANTONIO
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
78216-6256
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
210-481-7453
Provider Business Mailing Address Fax Number:
210-481-7463

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
205 W WINDCREST ST
Provider Second Line Business Practice Location Address:
SUITE 230
Provider Business Practice Location Address City Name:
FREDERICKSBURG
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
78624-4479
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
830-997-0296
Provider Business Practice Location Address Fax Number:
830-997-0310
Provider Enumeration Date:
09/28/2010

Additional Information

Authorized Official

Authorized Official Last Name:
ROBY
Authorized Official First Name:
CLAY
Authorized Official Middle Name:
Authorized Official Title or Position:
EXECUTIVE DIRECTOR
Authorized Official Telephone Number:
210-661-5622

Provider Taxonomy Codes

  • Taxonomy code: 207RN0300X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 363LF0000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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





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