Provider Demographics
NPI:1629295621
Name:KELL PRIMARY CARE PA
Entity Type:Organization
Organization Name:KELL PRIMARY CARE PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNERMEMBER
Authorized Official - Prefix:
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:C
Authorized Official - Last Name:HULL
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:940-692-6200
Mailing Address - Street 1:5500 KELL WEST BLVD
Mailing Address - Street 2:SUITE 500
Mailing Address - City:WICHITA FALLS
Mailing Address - State:TX
Mailing Address - Zip Code:76310
Mailing Address - Country:US
Mailing Address - Phone:940-692-6200
Mailing Address - Fax:940-692-6206
Practice Address - Street 1:5500 KELL WEST BLVD
Practice Address - Street 2:SUITE 500
Practice Address - City:WICHITA FALLS
Practice Address - State:TX
Practice Address - Zip Code:76310
Practice Address - Country:US
Practice Address - Phone:940-692-6200
Practice Address - Fax:940-692-6206
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-19
Last Update Date:2008-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX00X909Medicare PIN