Provider Demographics
NPI:1760631832
Name:MULTI-SPECIALTY DIAGNOSTIC CENTER REBECCA A PREISS GEN PTR
Entity type:Organization
Organization Name:MULTI-SPECIALTY DIAGNOSTIC CENTER REBECCA A PREISS GEN PTR
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:JEROME
Authorized Official - Middle Name:D
Authorized Official - Last Name:KIZZART
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:830-815-1202
Mailing Address - Street 1:6511 US HIGHWAY 181 N
Mailing Address - Street 2:SUITE 1
Mailing Address - City:FLORESVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:78114-6281
Mailing Address - Country:US
Mailing Address - Phone:830-815-1202
Mailing Address - Fax:830-815-1205
Practice Address - Street 1:6511 US HIGHWAY 181 N
Practice Address - Street 2:SUITE 1
Practice Address - City:FLORESVILLE
Practice Address - State:TX
Practice Address - Zip Code:78114-6281
Practice Address - Country:US
Practice Address - Phone:830-815-1202
Practice Address - Fax:830-815-1205
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-09-15
Last Update Date:2010-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXH3823207P00000X, 2083P0011X, 208M00000X, 207R00000X
TXM6603207RC0200X, 207RP1001X, 207RS0012X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No207P00000XAllopathic & Osteopathic PhysiciansEmergency MedicineGroup - Multi-Specialty
No207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care MedicineGroup - Multi-Specialty
No207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary DiseaseGroup - Multi-Specialty
No207RS0012XAllopathic & Osteopathic PhysiciansInternal MedicineSleep MedicineGroup - Multi-Specialty
No2083P0011XAllopathic & Osteopathic PhysiciansPreventive MedicineUndersea and Hyperbaric MedicineGroup - Multi-Specialty
No208M00000XAllopathic & Osteopathic PhysiciansHospitalistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX95RTOtherBCBS
TX95RTOtherBCBS