Basic Information
| Provider Information | |||||||||
| NPI: | 1720138449 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | FIVE STAR EMERGENCY PHYSICIANS PA | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | KILLEEN EMERGENCY PHYSICIANS PA | ||||||||
| OtherOrganizationType: | 4 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6300 LA CALMA DR | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | AUSTIN | ||||||||
| State: | TX | ||||||||
| PostalCode: | 787523843 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5124528533 | ||||||||
| FaxNumber: | 5124529306 | ||||||||
| Practice Location | |||||||||
| Address1: | 850 W CENTRAL TEXAS EXPY | ||||||||
| Address2: | |||||||||
| City: | HARKER HEIGHTS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 765481890 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2546900900 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/12/2007 | ||||||||
| LastUpdateDate: | 05/08/2012 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | ROBERTS | ||||||||
| AuthorizedOfficialFirstName: | SAM | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 5124528533 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 0051PV | 01 | TX | BCBS | OTHER | 0016PL | 01 | TX | BCBS | OTHER | 187376201 | 05 | TX | MEDICAID |