Provider Demographics
NPI:1730519158
Name:MEDICAL SURGICAL SPECIALIST OF KERRVILLE, PA
Entity type:Organization
Organization Name:MEDICAL SURGICAL SPECIALIST OF KERRVILLE, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICER MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:
Authorized Official - Last Name:HUGHES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:830-896-5005
Mailing Address - Street 1:1001 WATER ST STE D-200
Mailing Address - Street 2:
Mailing Address - City:KERRVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:78028-3566
Mailing Address - Country:US
Mailing Address - Phone:830-896-5005
Mailing Address - Fax:830-896-4747
Practice Address - Street 1:1001 WATER ST STE D-200
Practice Address - Street 2:
Practice Address - City:KERRVILLE
Practice Address - State:TX
Practice Address - Zip Code:78028-3566
Practice Address - Country:US
Practice Address - Phone:830-896-5005
Practice Address - Fax:830-896-4747
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-11-21
Last Update Date:2020-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXG2979174400000X
TXH9895174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX136809405Medicaid
TX097289502Medicaid
TX00N72VMedicare PIN
TX00A76HMedicare PIN
TX136809405Medicaid
TXC16431Medicare UPIN