=====================================================
General NPI Number Information
=====================================================
NPI Number | 1710147285
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | JEROME D. KIZZART, M.D./REBECCA PREISS GEN PTR
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/09/2008
-----------------------------------------------------
Last Update Date | 09/03/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 6511 US HIGHWAY 181 N SUITE 1
-----------------------------------------------------
City | FLORESVILLE
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78114-6281
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 830-393-2400
-----------------------------------------------------
Fax | 830-393-2488
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 6511 US HIGHWAY 181 N SUITE 1
-----------------------------------------------------
City | FLORESVILLE
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78114-6281
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 830-393-2400
-----------------------------------------------------
Fax | 830-393-2488
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/PHYSICIAN
-----------------------------------------------------
Name | DR. JEROME D KIZZART
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 210-323-5233
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207P00000X
-----------------------------------------------------
Taxonomy Name | Emergency Medicine Physician
-----------------------------------------------------
License Number | H3823
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207RS0012X
-----------------------------------------------------
Taxonomy Name | Sleep Medicine (Internal Medicine) Physician
-----------------------------------------------------
License Number | H3823
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 2083P0011X
-----------------------------------------------------
Taxonomy Name | Undersea and Hyperbaric Medicine (Preventive Medicine) Physician
-----------------------------------------------------
License Number | H3823
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------
Taxonomy #4
-----------------------------------------------------
Taxonomy Code | 208M00000X
-----------------------------------------------------
Taxonomy Name | Hospitalist Physician
-----------------------------------------------------
License Number | H3823
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------
Taxonomy #5
-----------------------------------------------------
Taxonomy Code | 207R00000X
-----------------------------------------------------
Taxonomy Name | Internal Medicine Physician
-----------------------------------------------------
License Number | H3823
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------