Basic Information
| Provider Information | |||||||||
| NPI: | 1811172620 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | FEFERMAN | ||||||||
| FirstName: | KERY | ||||||||
| MiddleName: | L. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4107 SPICEWOOD SPRINGS RD STE 100 | ||||||||
| Address2: | |||||||||
| City: | AUSTIN | ||||||||
| State: | TX | ||||||||
| PostalCode: | 787598645 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5123973360 | ||||||||
| FaxNumber: | 1234371075 | ||||||||
| Practice Location | |||||||||
| Address1: | 4107 SPICEWOOD SPRINGS RD STE 100 | ||||||||
| Address2: | |||||||||
| City: | AUSTIN | ||||||||
| State: | TX | ||||||||
| PostalCode: | 787598645 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5121397336 | ||||||||
| FaxNumber: | 5123437107 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/31/2007 | ||||||||
| LastUpdateDate: | 11/10/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 11/10/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207L00000X | M7967 | TX | N | Allopathic & Osteopathic Physicians | Anesthesiology | 207LP2900X | M7967 | TX | N | Allopathic & Osteopathic Physicians | Anesthesiology | Pain Medicine | 208VP0014X | M7967 | TX | Y | Allopathic & Osteopathic Physicians | Pain Medicine | Interventional Pain Medicine |
ID Information
| ID | Type | State | Issuer | Description | 2045015-08 | 05 | TX | MEDICAID | 204501504 | 05 | TX | MEDICAID | 204501503 | 05 | TX | MEDICAID |