Basic Information
| Provider Information | |||||||||
| NPI: | 1619213873 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | PHYSICIANS OF KING'S DAUGHTERS, PA | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | KING'S DAUGHTERS CLINIC | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1905 SW H K DODGEN LOOP | ||||||||
| Address2: | |||||||||
| City: | TEMPLE | ||||||||
| State: | TX | ||||||||
| PostalCode: | 765021814 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2542982682 | ||||||||
| FaxNumber: | 2547787197 | ||||||||
| Practice Location | |||||||||
| Address1: | 800 W CENTRAL TEXAS EXPY | ||||||||
| Address2: | |||||||||
| City: | HARKER HEIGHTS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 765481899 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2542982682 | ||||||||
| FaxNumber: | 2547787197 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/17/2012 | ||||||||
| LastUpdateDate: | 12/17/2012 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | MINER | ||||||||
| AuthorizedOfficialFirstName: | VIRGINIA | ||||||||
| AuthorizedOfficialMiddleName: | RL | ||||||||
| AuthorizedOfficialTitleorPosition: | CREDENTIALING COORDINATOR | ||||||||
| AuthorizedOfficialTelephone: | 2542982682 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RI0011X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Interventional Cardiology |
ID Information
| ID | Type | State | Issuer | Description | 110836702 | 05 | TX | MEDICAID | 00C399 | 01 | TX | GROUP MEDICARE NUMBER | OTHER |