Basic Information
| Provider Information | |||||||||
| NPI: | 1265603971 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | SAN ANTONIO KIDNEY DISEASE CENTER PHYSICIANS GROUP, P.L.L.C. | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | SAKDC | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 7142 SAN PEDRO AVE | ||||||||
| Address2: | STE 120 | ||||||||
| City: | SAN ANTONIO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 782166256 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2104817453 | ||||||||
| FaxNumber: | 2104817463 | ||||||||
| Practice Location | |||||||||
| Address1: | 5000 BAPTIST HEALTH DR | ||||||||
| Address2: | STE 116 | ||||||||
| City: | SCHERTZ | ||||||||
| State: | TX | ||||||||
| PostalCode: | 781541193 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2109450200 | ||||||||
| FaxNumber: | 2105908232 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/20/2008 | ||||||||
| LastUpdateDate: | 04/10/2014 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | ROBY | ||||||||
| AuthorizedOfficialFirstName: | CLAY | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | EXECUTIVE DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 2106615622 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 207RN0300X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Nephrology |
No ID Information.