Healthcare Provider Details

I. General information

NPI: 1073880092
Provider Name (Legal Business Name): KELLUM PHYSICIAN PARTNERS, PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/18/2011
Last Update Date: 04/07/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3903 WISEMAN BLVD SUITE 215
SAN ANTONIO TX
78251-4401
US

IV. Provider business mailing address

8870 US HIGHWAY 87 E
SAN ANTONIO TX
78263-2242
US

V. Phone/Fax

Practice location:
  • Phone: 210-675-6724
  • Fax: 210-675-1759
Mailing address:
  • Phone: 210-648-0152
  • Fax: 210-649-4170

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberJ1533
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License NumberJ0844
License Number StateTX

VIII. Authorized Official

Name: DANIEL HANSFORD KELLUM JR.
Title or Position: PRESIDENT
Credential: M.D.
Phone: 210-945-2121