MEDICARE: SAN ANTONIO KIDNEY DISEASE CENTER PHYSICIANS GROUP, P.L.L.C.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QA1903X	Ambulatory Surgical Clinic/Center

General Provider Information

NPI Number	:	1417594995
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SAN ANTONIO KIDNEY DISEASE CENTER PHYSICIANS GROUP, P.L.L.C.

Provider Business Mailing Address
First Line	:	7142 SAN PEDRO AVE STE 120
Second Line	:
City	:	SAN ANTONIO
State	:	TX
Zip	:	78216-6256
Country	:	US
Telephone Number	:	210-661-5622
Fax Number	:

Provider Business Practice Location Address
First Line	:	7114 SAN PEDRO AVE
Second Line	:
City	:	SAN ANTONIO
State	:	TX
Zip	:	78216-6218
Country	:	US
Telephone Number	:	210-342-2233
Fax Number	:

Authorized Official
Title or Position	:	EXECUTIVE DIRECTOR
Name	:	CLAIBORNE B. ROBY
Credential	:
Telephone Number	:	210-661-5622

Provider Enumeration Date	:	12/04/2019
Last Update Date	:	12/04/2019

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