Provider Demographics
NPI:1871666271
Name:CENTRAL TEXAS HEART CENTER
Entity Type:Organization
Organization Name:CENTRAL TEXAS HEART CENTER
Other - Org Name:PROF ASSOCIATION
Other - Org Type:Other Name
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:KENNON
Authorized Official - Middle Name:D
Authorized Official - Last Name:WIGLEY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:979-774-4008
Mailing Address - Street 1:2700 E 29TH ST
Mailing Address - Street 2:SUITE 220
Mailing Address - City:BRYAN
Mailing Address - State:TX
Mailing Address - Zip Code:77802-2531
Mailing Address - Country:US
Mailing Address - Phone:979-774-4008
Mailing Address - Fax:979-774-7893
Practice Address - Street 1:2700 E 29TH STREET
Practice Address - Street 2:SUITE 220
Practice Address - City:BRYAN
Practice Address - State:TX
Practice Address - Zip Code:77802-2586
Practice Address - Country:US
Practice Address - Phone:979-774-4008
Practice Address - Fax:979-774-7893
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-16
Last Update Date:2013-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular DiseaseGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX082010201Medicaid
CD6802OtherRAILROAD MEDICARE
TX082010201Medicaid