Basic Information
| Provider Information | |||||||||
| NPI: | 1013960228 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KILLAM | ||||||||
| FirstName: | RONALD | ||||||||
| MiddleName: | WAYNE | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 96406 | ||||||||
| Address2: | |||||||||
| City: | HOUSTON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 772136406 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7133300766 | ||||||||
| FaxNumber: | 8778628370 | ||||||||
| Practice Location | |||||||||
| Address1: | 11821 EAST FWY STE 175 | ||||||||
| Address2: | |||||||||
| City: | HOUSTON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 770291960 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7133300766 | ||||||||
| FaxNumber: | 8778628370 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/18/2006 | ||||||||
| LastUpdateDate: | 04/02/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | H5715 | TX | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 10014941 | 05 | TX | MEDICAID | 8Z1542 | 01 | TX | BLUECROSS BLUESHIELD | OTHER | 111525501 | 05 | TX | MEDICAID | 111525504 | 05 | TX | MEDICAID | 810621291 | 01 | TX | TAX IDENTIFICATION | OTHER | 111525505 | 05 | TX | MEDICAID | 1518219104 | 01 | TX | GROUP NPI | OTHER | 460986471 | 01 | TX | TAX IDENTIFICATION | OTHER | 00511B | 01 | TX | BLUECROSS BLUESHIELD | OTHER | 8K3280 | 01 | TX | BLUE CROSS SHIELD | OTHER |