Provider Demographics
NPI:1013107853
Name:RICHARD SCOTT KOBYLAR J C TANENBAUM DPM PA & ASSOCIATES
Entity Type:Organization
Organization Name:RICHARD SCOTT KOBYLAR J C TANENBAUM DPM PA & ASSOCIATES
Other - Org Name:J.C. TANENBAUM, DPM, PA, AND ASSOCIATES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:SCOTT
Authorized Official - Last Name:KOBYLAR
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:979-245-9500
Mailing Address - Street 1:600 HOSPITAL CIR STE 103
Mailing Address - Street 2:
Mailing Address - City:BAY CITY
Mailing Address - State:TX
Mailing Address - Zip Code:77414-4772
Mailing Address - Country:US
Mailing Address - Phone:979-245-9000
Mailing Address - Fax:979-323-7370
Practice Address - Street 1:600 HOSPITAL CIR STE 103
Practice Address - Street 2:
Practice Address - City:BAY CITY
Practice Address - State:TX
Practice Address - Zip Code:77414-4772
Practice Address - Country:US
Practice Address - Phone:979-245-9500
Practice Address - Fax:979-323-7370
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-27
Last Update Date:2020-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1691213ES0103X, 332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty
No332B00000XSuppliersDurable Medical Equipment & Medical SuppliesGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX181694401Medicaid
TX5843510001Medicare NSC
TXV01592Medicare UPIN