=====================================================
General NPI Number Information
=====================================================
NPI Number | 1346322625
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ANDREW H KILGUS MD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/19/2006
-----------------------------------------------------
Last Update Date | 05/04/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1600 W NORTHWEST HWY STE 900
-----------------------------------------------------
City | GRAPEVINE
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 76051-8112
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 817-488-7573
-----------------------------------------------------
Fax | 817-488-5096
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 99371
-----------------------------------------------------
City | FORT WORTH
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 76199-0371
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 682-885-1855
-----------------------------------------------------
Fax | 682-885-7347
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208000000X
-----------------------------------------------------
Taxonomy Name | Pediatrics Physician
-----------------------------------------------------
License Number | G4326
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------