Healthcare Provider Details

I. General information

NPI: 1043626955
Provider Name (Legal Business Name): KENNY-BAO THAI TRAN, MD, PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/11/2014
Last Update Date: 05/28/2021
Certification Date: 05/28/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2000 SCENIC DR
GEORGETOWN TX
78626-7726
US

IV. Provider business mailing address

PO BOX 924
AUSTIN TX
78767-0924
US

V. Phone/Fax

Practice location:
  • Phone: 512-942-4700
  • Fax:
Mailing address:
  • Phone: 512-474-5700
  • Fax: 512-474-2720

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License Number
License Number State

VIII. Authorized Official

Name: KENNY-BAO THAI TRAN
Title or Position: OWNER
Credential: MD
Phone: 512-942-4700