Provider Demographics
NPI:1578599924
Name:KILLEEN NEUROLOGY, PA
Entity Type:Organization
Organization Name:KILLEEN NEUROLOGY, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:SHAMSUDDIN
Authorized Official - Middle Name:
Authorized Official - Last Name:KHWAJA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:254-554-3377
Mailing Address - Street 1:PO BOX 938
Mailing Address - Street 2:
Mailing Address - City:KILLEEN
Mailing Address - State:TX
Mailing Address - Zip Code:76540-0938
Mailing Address - Country:US
Mailing Address - Phone:254-634-6999
Mailing Address - Fax:254-200-4090
Practice Address - Street 1:2105 S CLEAR CREEK RD
Practice Address - Street 2:
Practice Address - City:KILLEEN
Practice Address - State:TX
Practice Address - Zip Code:76549-4110
Practice Address - Country:US
Practice Address - Phone:254-554-3377
Practice Address - Fax:254-554-3389
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-25
Last Update Date:2010-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXL9285174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX173994801Medicaid
TX0003MSOtherBLUE CROSS BLUE SHIELD
TXDC5542OtherMEDICARE RAILRAOD
TX00864XMedicare PIN