Provider Demographics
NPI:1477685485
Name:SOUTH KATY MEDICAL CLINIC, P.A.
Entity Type:Organization
Organization Name:SOUTH KATY MEDICAL CLINIC, P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DOCTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:EDWARD
Authorized Official - Last Name:KENDALL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:281-395-6996
Mailing Address - Street 1:22028 HIGHLAND KNOLLS DR
Mailing Address - Street 2:BLDG. #D
Mailing Address - City:KATY
Mailing Address - State:TX
Mailing Address - Zip Code:77450-5859
Mailing Address - Country:US
Mailing Address - Phone:281-395-6996
Mailing Address - Fax:281-395-6919
Practice Address - Street 1:22028 HIGHLAND KNOLLS
Practice Address - Street 2:BLDG #D
Practice Address - City:KATY
Practice Address - State:TX
Practice Address - Zip Code:77450-5859
Practice Address - Country:US
Practice Address - Phone:281-395-6996
Practice Address - Fax:281-395-6919
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-12
Last Update Date:2012-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX00012TOtherBC/BS TEXAS
TX149260501Medicaid
TX149260501Medicaid