Provider Demographics
NPI:1265565691
Name:DEKALB PHYSICIANS CLINIC LLC
Entity type:Organization
Organization Name:DEKALB PHYSICIANS CLINIC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER - PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:KYLE
Authorized Official - Middle Name:WAYNE
Authorized Official - Last Name:GROOM
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:903-667-2273
Mailing Address - Street 1:216 N CENTRE ST
Mailing Address - Street 2:
Mailing Address - City:DE KALB
Mailing Address - State:TX
Mailing Address - Zip Code:75559-1406
Mailing Address - Country:US
Mailing Address - Phone:903-667-2273
Mailing Address - Fax:903-667-7597
Practice Address - Street 1:1250 S RUNNELS ST
Practice Address - Street 2:
Practice Address - City:DE KALB
Practice Address - State:TX
Practice Address - Zip Code:75559-2317
Practice Address - Country:US
Practice Address - Phone:903-667-2273
Practice Address - Fax:903-667-7597
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-14
Last Update Date:2023-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXL5749207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8S7090OtherBLUE CROSS BLUE SHIELD
TX177214701Medicaid
AR8P152OtherARK BLUE CROSS BLUE SHIEL
TX00429ZMedicare PIN