Provider Demographics
NPI:1508813494
Name:KELLUM MEDICAL GROUP, PA
Entity Type:Organization
Organization Name:KELLUM MEDICAL GROUP, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE AUTHORIZED OFFICIAL
Authorized Official - Prefix:
Authorized Official - First Name:EVA
Authorized Official - Middle Name:L
Authorized Official - Last Name:HERNANDEZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:210-231-2540
Mailing Address - Street 1:7323 MARBACH RD STE 104
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78227-1905
Mailing Address - Country:US
Mailing Address - Phone:210-674-0257
Mailing Address - Fax:210-369-9064
Practice Address - Street 1:7323 MARBACH RD STE 104
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78227-1905
Practice Address - Country:US
Practice Address - Phone:210-674-0257
Practice Address - Fax:210-369-9064
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-27
Last Update Date:2024-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Multi-Specialty
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty
No363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatricsGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1174518625OtherDANIEL H KELLUM SR., DO - NPI
TX1508813494OtherGROUP NPI#
TX1588641377OtherSALVADOR C VAZQUEZ, MD - NPI
TX1063070308OtherMANUELA BERRY, NP-C / NPI#
TX1265413264OtherALICE T. BLACKMON, NP-C / NPI#
TX1346646510OtherMATTHEW ARISMENDEZ, PA-C / NPI#
TX0925166-02OtherEPSDT MEDICAID
TX1134467483OtherYOLANDA L. VALDES, PA / NPI#
TX0925166-01OtherTRADITIONAL MEDICAID GRP
TX1396908950OtherDENISE KELLUM, PA - NPI