=====================================================
General NPI Number Information
=====================================================
NPI Number | 1578593224
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | K S MANAGEMENT SERVICES LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/04/2006
-----------------------------------------------------
Last Update Date | 08/19/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2727 W HOLCOMBE BLVD ASC, 3RD FLOOR
-----------------------------------------------------
City | HOUSTON
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77025-1669
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 713-442-3300
-----------------------------------------------------
Fax | 713-442-3332
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2617C W HOLCOMBE BLVD PMB 312
-----------------------------------------------------
City | HOUSTON
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77025-1601
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 713-442-3300
-----------------------------------------------------
Fax | 713-442-5833
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MANAGING DIRECTOR
-----------------------------------------------------
Name | DR. SPENCER BERTHELSEN
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 713-442-0000
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QA1903X
-----------------------------------------------------
Taxonomy Name | Ambulatory Surgical Clinic/Center
-----------------------------------------------------
License Number | 007124
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------