Basic Information
| Provider Information | |||||||||
| NPI: | 1518276328 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SAN ANTONIO KIDNEY DISEASE CENTER PHYSICIANS GROUP, P.L.L.C. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 7142 SAN PEDRO AVE | ||||||||
| Address2: | SUITE 120 | ||||||||
| City: | SAN ANTONIO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 782166254 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2106615622 | ||||||||
| FaxNumber: | 2104817463 | ||||||||
| Practice Location | |||||||||
| Address1: | 7515 BARLITE BLVD | ||||||||
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| City: | SAN ANTONIO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 782241311 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2102771011 | ||||||||
| FaxNumber: | 2102771090 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/28/2010 | ||||||||
| LastUpdateDate: | 09/28/2010 | ||||||||
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| AuthorizedOfficialLastName: | ROBY | ||||||||
| AuthorizedOfficialFirstName: | CLAY | ||||||||
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| AuthorizedOfficialTitleorPosition: | EXECUTIVE DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 2106615622 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 207RN0300X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Nephrology |
No ID Information.