Provider Demographics
NPI:1114292968
Name:KERRVILLE PEDIATRICS
Entity Type:Organization
Organization Name:KERRVILLE PEDIATRICS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:CONNIE
Authorized Official - Middle Name:LEA
Authorized Official - Last Name:WHIITNG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:830-257-1440
Mailing Address - Street 1:1331 BANDERA HWY
Mailing Address - Street 2:SUITE 10
Mailing Address - City:KERRVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:78028-9535
Mailing Address - Country:US
Mailing Address - Phone:830-257-1440
Mailing Address - Fax:830-257-2542
Practice Address - Street 1:1331 BANDERA HWY
Practice Address - Street 2:SUITE 10
Practice Address - City:KERRVILLE
Practice Address - State:TX
Practice Address - Zip Code:78028-9535
Practice Address - Country:US
Practice Address - Phone:830-257-1440
Practice Address - Fax:830-257-2542
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-03-13
Last Update Date:2012-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX230898364SP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes364SP0200XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistPediatricsGroup - Single Specialty