Provider Demographics
NPI:1639405855
Name:KERRVILLE MED EXPRESS
Entity Type:Organization
Organization Name:KERRVILLE MED EXPRESS
Other - Org Name:INTERNATIONAL FAMILY CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHYSICIAN/MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:BRUCE
Authorized Official - Last Name:DEBENEDETTO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:956-761-4649
Mailing Address - Street 1:2217 PADRE BLVD
Mailing Address - Street 2:
Mailing Address - City:SOUTH PADRE ISLAND
Mailing Address - State:TX
Mailing Address - Zip Code:78597
Mailing Address - Country:US
Mailing Address - Phone:956-761-4649
Mailing Address - Fax:866-594-1025
Practice Address - Street 1:2217 PADRE BLVD
Practice Address - Street 2:
Practice Address - City:SOUTH PADRE ISLAND
Practice Address - State:TX
Practice Address - Zip Code:78597
Practice Address - Country:US
Practice Address - Phone:956-761-4649
Practice Address - Fax:866-594-1025
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-10-22
Last Update Date:2013-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXJ9579207PE0004X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
No207PE0004XAllopathic & Osteopathic PhysiciansEmergency MedicineEmergency Medical ServicesGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8CE910OtherBCBSTX
TX113326621Medicaid
TX8CE910OtherBCBSTX
TX8F23012Medicare PIN
TX0A5310Medicare PIN