Provider Demographics
NPI:1508813494
Name:KELLUM MEDICAL GROUP, PA
Entity type:Organization
Organization Name:KELLUM MEDICAL GROUP, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING AUTHORIZED OFFICIAL
Authorized Official - Prefix:
Authorized Official - First Name:KRISTI
Authorized Official - Middle Name:
Authorized Official - Last Name:BRAKER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:210-674-0257
Mailing Address - Street 1:7323 MARBACH RD STE 104
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78227-1905
Mailing Address - Country:US
Mailing Address - Phone:210-674-0257
Mailing Address - Fax:210-369-9064
Practice Address - Street 1:7323 MARBACH RD STE 104
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78227-1905
Practice Address - Country:US
Practice Address - Phone:210-674-0257
Practice Address - Fax:210-369-9064
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-27
Last Update Date:2025-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Multi-Specialty
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedicalGroup - Multi-Specialty
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty
No363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatricsGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX45D1026258OtherCLIA - KELLUM MEDICAL GROUP, PA - PEDIATRICS
TX1174518625OtherDANIEL H KELLUM SR., DO - NPI
TXCH6982OtherMEDICARE RR GROUP PTAN#
TX1265413264OtherALICE T. BLACKMON, NP-C / NPI#
TX1588641377OtherSALVADOR VAZQUEZ, MD / NPI#
TX193200000XOtherGROUP TAXONOMY
TX1346646510OtherMATTHEW ARISMENDEZ, PA-C / NPI#
TXR-14400OtherRADIOLOGY & X-RAY CERT#
TX00295NOtherMEDICARE GROUP PTAN#
TX1063070308OtherMANUELA BERRY, NP-C / NPI#
TX45D0671939OtherCLIA - KELLUM MEDICAL GROUP, PA
TX1366623639OtherKIMBERLY 'KIM' DIAZ, PA-C
TX1508813494Medicaid