MEDICARE: SAN ANTONIO KIDNEY DISEASE CENTER PHYSICIANS GROUP, P.L.L.C.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LF0000X	Family Nurse Practitioner
2	207RN0300X	Nephrology Physician

General Provider Information

NPI Number	:	1467707240
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SAN ANTONIO KIDNEY DISEASE CENTER PHYSICIANS GROUP, P.L.L.C.

Provider Business Mailing Address
First Line	:	7142 SAN PEDRO AVE
Second Line	:	SUITE 120
City	:	SAN ANTONIO
State	:	TX
Zip	:	78216-6256
Country	:	US
Telephone Number	:	210-481-7453
Fax Number	:	210-481-7463

Provider Business Practice Location Address
First Line	:	2902 GOLIAD RD
Second Line	:	SUITE 103
City	:	SAN ANTONIO
State	:	TX
Zip	:	78223-3971
Country	:	US
Telephone Number	:	210-337-4911
Fax Number	:	210-337-7749

Authorized Official
Title or Position	:	EXECUTIVE DIRECTOR
Name	:	CLAY ROBY
Credential	:
Telephone Number	:	210-481-7453

Provider Enumeration Date	:	07/18/2012
Last Update Date	:	04/10/2014

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