Provider Demographics
NPI:1740327642
Name:KENNETH R HART DO PA
Entity type:Organization
Organization Name:KENNETH R HART DO PA
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT AND MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:KENNETH
Authorized Official - Middle Name:RALPH
Authorized Official - Last Name:HART
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:210-732-7030
Mailing Address - Street 1:6800 PARK TEN BLVD
Mailing Address - Street 2:SUITE 266-S
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78213-4211
Mailing Address - Country:US
Mailing Address - Phone:210-732-7030
Mailing Address - Fax:210-732-7575
Practice Address - Street 1:414 NAVARRO ST
Practice Address - Street 2:SUITE 502
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78205-2516
Practice Address - Country:US
Practice Address - Phone:210-223-1145
Practice Address - Fax:210-615-7619
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-31
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXF8504174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX0812851001Medicaid
TX00860NMedicare ID - Type UnspecifiedMEDICARE GROUP IDENTIFIER
TX0812851001Medicaid